St. John’s Regional Health Center: Following Heart Failure Patients After Discharge Avoids Readmissions

St. John’s Regional Health Center (St. John's) has very low readmission rates among patients with heart attacks, heart failure, and pneumonia—the three conditions for which hospitals report readmission rates to the Centers for Medicare and Medicaid Services (CMS). Its rates are better than the top 10 percent of hospitals reporting (Exhibit 1).

St. John's, like other hospitals profiled in this case study series, did not set out deliberately to reduce readmission rates. Rather, the hospital has had a longterm commitment to establishing and adhering to care standards to deliver optimal care. Staff follow evidence-based practices, educate patients about their conditions during their stay and after discharge, provide coordinated care, and manage chronic diseases by working with providers in the hospital and community.

In addition, St. John's low readmission rates for heart attack and heart failure patients may be attributed to the close attention it pays to patients after discharge and its engagement of the community's primary care physicians. Further, being part of a system and working in partnership with its health plan have influenced how the hospital approaches care coordination and cost-effective care.

This case study focuses on St. John's strategies and efforts to improve heart attack and heart failure care and reduce related readmissions.

Patient-focused interventions after discharge

• telephone calls to all heart failure patients to answer questions and remind them about the importance of having a follow-up visit with their personal physician;
• referrals to an outpatient cardiac rehabilitation program;
• use of an interactive voice response telemonitoring program for heart failure patients;
• 24-hour nurse triage help line to provide after-hours support;
• medication assistance program for patients with limited resources; and
• 24- to 48-hour follow-up by a St. John’s Health Plans care manager (for health plan members) to review discharge instructions, ensure patients have appointments with their personal physicians, check medications, and remove any barriers to following treatment plans.

Interventions focused on community providers

• telephone and electronic notification to patients’ personal physicians about patients' hospitalization and need for follow-up visits within one week;
• "call in, get in" standard of care, in which personal physicians make heart failure patients a priority; and
• an electronic heart failure registry to track such patients' care over time.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.