Emerson Hospital already had one of the lowest 30-day readmission rates in the state of Massachusetts, but when an opportunity came along to lower rates even further among its high-risk patients, the hospital jumped at the opportunity.

In 2015, Emerson Hospital, located in Concord, 20 miles northwest of Boston, was awarded a $1.2 million grant from the Massachusetts Health Policy Commission as part of the Community Hospital Acceleration Revitalization and Transformation Program, or CHART. The statewide program includes 27 community hospitals with a shared goal of reducing 30-day readmission rates among high risk-patients at their respective institutions.

While Emerson’s readmission rates were already better than the state average, improvements made during the grant’s two-year span have lowered readmission rates among the hospital's high-risk patients by 24 percent. Additionally, patient satisfaction has dramatically improved, as demonstrated by Emerson’s HCAHPS scores now trending in the 96th percentile in Massachusetts. When the hospital first started CHART, its transitional care patient satisfaction rate was hovering around 65 percent.

Achieving these numbers, however, didn’t happen overnight. It required a change in culture and stronger coordination both within the hospital and across the community.

The grant allowed for staff to critically analyze their high-risk patient population and ask exactly who were the high-risk patients that the hospital needed to be most concerned about, says Margaret Foley, R.N., director of care management at Emerson.

That high-risk population included patients with chronic conditions, such as heart failure, chronic obstructive pulmonary disease, chronic renal failure, stroke, diabetes and some types of cancer. There were also high readmission rates among patients returning from a local skilled nursing facility within 30 days.

Emerson looked within its hospital walls to better address the needs of high-risk patients by placing a renewed focus on them — educating staff on addressing needs from the perspective of the patients, their families and their caregivers. Asking questions like: How were they functioning at home? What was life like for them? Have their health goals changed? And how do we take in and use that information? Foley says.

“We always did those things, but now we had a more unified approach to those high-risk patients and began really making sure we met those needs,” Foley added.

Additionally, new staff were brought in and interdisciplinary teams were created to care for the entirety of patients' needs. A nurse navigator had already been in place to make sure that more than just clinical needs were being met, and dedicated social workers, care transition nurses, navigators and pharmacists joined the team to provide more well-rounded care. And a community worker is now able to help patients get to appointments on time, understand what a doctor tells them and follow up after they’re outside the hospital walls.

Increased communication with post-acute care facilities in the community has also contributed to the decline in readmissions, says Foley.

Meetings take place between Foley’s team and local skilled facilities each month where staff review rehospitalization rates and reinforce best practices. Patient handoffs between the hospital and community facilities have also expanded beyond nurse-to-nurse interactions and now include social workers and physicians communicating to maximize care for high-risk patients.

“Everyone is so well-aware of the patient and [his or her] needs,” says Foley.

The CHART program grant concluded in September, but Foley says the team is dedicated to continuing to improve care for its high-risk population.