One in four HIV-positive individuals admitted to a hospital in southwestern Pennsylvania is readmitted within 30 days. Literature provides evidence that comprehensive primary care, including patient education and care management, can significantly reduce hospital readmissions. However, many HIV/AIDS providers find it challenging to find the time and resources to implement these best practices. This presentation will showcase how a Part C clinic reduced the rate of 30-day hospital readmissions through the adoption of Lean quality improvement strategies. It will also describe the FOCUS-PDSA model, low-tech intervention methods, process evaluation elements, and outcome measures associated with reducing hospital readmissions. Early results indicate the 30-day hospital readmission rate fell by more than 50 percent since implementation.
Learning Objectives:
- Participants will learn how to adopt a robust system to follow-up with their patients while in the hospital to make up for common challenges related to the discharge of complex patients. They will learn the steps that the clinic implemented to effectively reach out to their hospitalized clients during and after hospitalization.
- Participants will be introduced to the Lean process improvement methodology that has been successfully applied to wide variety of healthcare and social service settings around the country. Specifically, the HIV clinic at the heart of the program used concepts from this method to improve operations at the clinic that led to the reduction of 30-day hospital readmissions. Participants will participate in a Lean methodology training activity similar to one provided to the HIV clinic to introduce key concepts including unambiguous communication, workflow analysis and balancing, and process mapping.
- The third objective of this Participants will learn how to investigate whether hospital readmissions among HIV- positive individuals are an issue in their region. In SWPA the research indicated that this was an important HIV/AIDS related health disparity, as the rate of 30-day hospital readmissions was more than 50 percent higher than that of the general population. This issue is at the confluence of the National HIV/AIDS strategy (as an HIV/AIDS health disparity) and the Affordable Care Act (as a cost containment and care coordination issue).
