Cleveland Clinic monitors 30-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Comprehensive care coordination and care management for high-risk patients has been initiated in an effort to prevent unnecessary hospitalizations and emergency department visits.
Our efforts to decrease readmissions include:
- Daily Plan of Care Visits to coordinate care and discharge planning across the care team including the patient.
- Individualized Care Plans (ICPs) for patients with frequent hospital encounters.
- Readmissions risk score in electronic health record to focus efforts for highest risk patients.
- Timely follow-up visits following discharge to ensure smooth transition of care.