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Readmission and Recidivism Reduction Program Team Chairperson Lexy Damon accepts ICAHN’s IMPACT Award during ceremonies held at the I-Hotel in Champaign.

Illini Community Hospital, Pittsfield, was awarded the Illinois Critical Access Hospital Network’s IMPACT Award for readmission and recidivism reduction during ceremonies held November 10 at the I-Hotel and Conference Center, Champaign, IL.

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Participants vying for the award were encouraged to submit innovations implemented at their respective hospitals which initiated a new approach to improve patient relationships, implemented a new process flow or life-safety improvement, found a creative way to motivate and inspire staff, or foster a successful community project.

Working on reducing readmissions and focusing on high Emergency Department utilization is not new to Illini Community Hospital, but a recent social determinants of health benchmarking survey helped ICH to see that a huge population was possibly being missed. After evaluating diagnosis and reasons for return over a 12-month period for all ED 72-hour returns, the importance of having a primary care provider, access to care, communication, and related services (such as pharmacy) became clear to maintain patient services at the appropriate care level. Analysis found ICH’s patients with 72-hour ED returns to be in need of medications, without access to the needed primary or specialty provider (including dentists), concerned about changes in their condition, and not clear about their patient education.

To date, ICH has been able to reduce its 72-hour ED returns by approximately 5%. Based on the social determinant needs, placement, and education concerns, a fulltime care manager was relocated to the ED, and readmission interviews are conducted with all patients returning to the ED within 72 hours. Through case reviews of ED patients returning, Illini Community Hospital has a much better understanding of true patient needs.

While the diagnosis category yielding the most returns may change from month to month, the need to care-coordinate and better manage care of these patients is the significant trend that remains the same. Developing a better understanding of why patients return has helped ICH understand the need to change its educational process and how they follow up after discharge to provide better outcomes.

“We want to ensure that all patients feel valued while receiving care, and no one becomes ‘labeled.’ We want patients to leave understanding their plan of care, know that we check on them within 48 hours, and that they matter,” said Jennifer Mowen, Administrative Director, Performance Improvement, Illini Community Hospital.

Team members include Lexy Damon, Emergency Department Manager and Team Chairperson; Susan Chenoweth, Administrative Director of Nursing; Alyssa Heavner, Acute Care Manager; McKenzie Tomhave, Care Manager; Paige Taylor, Care Manager; Anita Wright, Quality Management; Kerensta Graham, Quality Management; Rhonda Smith, Care Coordination; and Missy Damon, Rural Health Clinic Manager. All team members participated in data analysis, process change, and evaluation.