The American Journal of Managed Care
November 2014
Volume 20
Issue 11

Care Coordination Measures of a Family Medicine Residency as a Model for Hospital Readmission Reduction

Utilization of the AHRQ Re-engineering Discharge model for Hospital Readmission Reduction produced marked readmission reduction in a Family Medicine residency with a 31% Medicaid population, through cooperation and care coordination between inpatient and outpatient settings.


The processes of care coordination of patient transition from hospital to outpatient settings are an integral part of the Patient-Centered Medical Home. We report a cooperative initiative between our admission hospital and family medicine residency to analyze the discharge process using the Agency for Healthcare Research and Quality’s Re-engineering Discharge initiative, focusing on efficient information transfer and communication with discharged patients to insure rapid follow-up in the clinic. Our project yielded markedly reduced readmission rates compared with both local hospital and national rates.

Am J Manag Care. 2014;20(11):e532-e534

CMS' Value-Based Purchasing places increasing responsibility upon healthcare providers to reduce hospital readmissions. This article describes the success of a family medicine residency with a 31% Medicaid patient population, achieved through:

  • Effective information flow between hospital and clinic.
  • Care coordination tracking and communication.
  • Division of tasks between hospital and outpatient practices.

Hospital readmission rate reduction is increasingly used both as a quality measure and a reimbursement determinant in CMS’ Value-Based Purchasing program. Despite the increasing financial incentives to reduce readmissions, however, the overall hospital discharge process remains surprisingly unstandardized. Increased readmission rates are associated with poor communication and information transfer to both patients1 and primary care physicians.2 Kripalani and colleagues (2007) noted that in 54% to 77% of discharges, discharge summaries were not available from the hospital 4 weeks after a patient was discharged from the hospital. We report here on 6 effective components of care coordination that have produced lower readmission rates compared with local hospital and national rates.

Table 1

Southern Illinois University (SIU) Family Medicine Residency in Decatur, Illinois, cares for a population with a 31% Medicaid payer mix. The residency functions as a patient-centered medical home (PCMH), and care coordination is a key component of its mission. In 2011, the SIU Family Medicine Residency partnered with our admitting hospital, Decatur Memorial Hospital, in an initiative called Project RED, based on an Agency for Healthcare Research and Quality (AHRQ) template called Re-engineering Discharge (see ). Responsibilities for each of the template’s 11 steps of the discharge process were assigned and coordinated between the hospital (5 steps) and the residency service (6 steps). We report on our improved discharge process and 30-day readmission rates.


SIU Family and Community Medicine Residency in Decatur, Illinois, sought to improve readmission rates at its partner hospital by implementing 2 overarching processes of care coordination and transition of care: 1) implementation of the electronic medical record (EMR) of SIU Family Medicine (which is different from the hospital EMR) in the hospital at the point of care to complete discharge summaries at the time of patient discharge; and 2) development of a care coordination team that tracks all discharges with telephone calls and verifies that a discharge summary will be ready in time for the patient’s post discharge visit. All of the 6 components of our discharge checklist are contingent on these 2 overarching processes.

Our target measure was that all patients discharged from the hospital receive a telephone call the next business day from a member of our care coordination staff, and are seen in clinic within 7 days post discharge. We analyzed readmissions at our primary admission hospital, Decatur Memorial Hospital, using the Illinois Hospital Association Comp-Data report from October 2011 to September 2012 for the top 5 admission diagnosis-related group diagnoses: chronic obstructive pulmonary disease, congestive heart failure, pneumonia, urinary tract infection, and skin infections. We measured readmission data from DMH, excluding our practice, and SIU FCM-only readmissions. Our study received an Institutional Review Board exemption for this analysis of the discharge process and readmission rates.

The AHRQ has created a best practice recommendation on the standardization of discharge processes. Called the Re-engineering Discharge (RED) checklist, it focuses on a mutually reinforcing checklist of 11 steps, as seen in Table 1 and has been adopted by the National Quality Forum as one of the 30 Safe Practices.3,4 Components 3, 4, 5, 6, 10, and 11 were most appropriate for our practice to focus on; Decatur Memorial focused on incorporating 1, 2, 7, 8, and 9 into its discharge process.

The discharge process, as practiced by our residency service, was analyzed by our Quality Improvement committee, with resident input, and retooled with the RED processes put into place as a part of the admission hospital’s goal to reduce unnecessary readmissions. It also fulfilled the Family Medicine residency training component in Patient Safety and Quality Improvement, which is a Graduate Medical Education-required component of Family Medicine. Table 1 describes the discharge processes on the recommended National Quality Forum checklist, and the respective assignments of responsibility shared between the admitting hospital and the SIU Family Medicine residency service.


Table 2

The 30-day readmission rates of our practice were noted and compared with local hospital and national rates (described in ).

Our reduced readmission rates are, we believe, due to the RED-inspired measures previously taken. Our practice underwent a quality improvement audit, focusing on July 1 to September 30, 2013, and we found that our target time to clinic appointment within 7 days was met 90% of the time; our mean time from discharge to appointment was 4.5 days; and our discharge summary documentation was completed, ready for the post discharge appointment, 100% of the time. These measures were all implemented before the analysis of our readmission rates that was done as part of our Care Coordination Team Quality Improvement study. The Care Coordination Team is responsible for tracking the discharged patients, telephoning them the next business day, scheduling their appointment, and tracking their attendance of the clinic appointment.


We believe that of the 11 recommended discharge “Safe Practices” checklist items, the elements that expedite information flow and coordinate the transition of care from hospital to clinic are essential to the primary care coordination process and will most effectively reduce readmissions of discharged hospital patients. A point-of-care electronic health record that flows immediately to the outpatient setting is crucial. Additionally, training physicians to effectively coordinate patient transition of care through efficient information flow and communication will positively affect the quality of healthcare in the current environment of reducing unnecessary expenditures, and will truly “add value” to both patients and payers.Author Affiliation: Southern Illinois University School of Medicine, Decatur Family Medicine Residency (WAM), Decatur, IL.

Source of Funding: None.

Author Disclosure: Mr Matthews reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Address correspondence to: Wayne A. Mathews, PA-C, MS, Director of Patient-Centered Outcomes Research, Southern Illinois University School of Medicine, Family Medicine, Decatur Family Medicine Residency, 250 W Kenwood Ave, Decatur, IL 62526. E-mail:

1. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991-994.

2. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.

3. Jack B. Project RED: Reengineering the hospital discharge process. Slide presentation given at: Agency for Healthcare Research and Quality 2009 Conference, Research to Reform: Achieving Health System Change; September 13-16, 2009; Bethesda, MD. Accessed June 2013.

4. National Quality Forum (NQF) Endorsed Set of 34 Safe Practices. HFAP website. Updatd February 2013. Accessed 2013.

5. Hospital Compare. 30-day unplanned readmission and death measures. website. Accessed October 2013.

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