The senior management team and board of trustees of Milford Regional Medical Center identified reducing avoidable readmissions as a hospital-wide goal. Although certain diagnoses contribute to the bulk of readmissions, Milford Regional identified medication, discharge planning, patient and family engagement, and social issues (transportation and nutrition) as key areas affecting readmissions.
The facility implemented the High Risk Mobile Team (HRMT) program, an unconventional and progressive approach to reducing readmissions, focusing on repairing gaps in the support structure for patients as they transition from hospital to home. At the hospital, an HRMT member meets with the patient and anticipates potential post-discharge needs. A colleague is then assigned to the case, participating in daily huddles with case managers and social workers to determine modifications upon discharge to prevent a readmission. Another team member will visit the patient at home, allowing them to identify and address barriers to medication, insurance coverage or basic needs. The pharmacist educates the patient on medication and dosage, and if needed, collaborates with the physician or the pharmaceutical manufacturer for an affordable medication so the patient receives the optimal treatment.
The efforts of the HRMT have shown a trend in reduction of avoidable readmissions over the past year. These efforts have also led to a reduction in the facility’s CMS readmission penalty patient population, thus potentially reducing readmission penalties. The HRMT has received accolades from patients and families for the care that is provided.
ABOUT MILFORD REGIONAL MEDICAL CENTER
Milford Regional Medical Center is a comprehensive healthcare facility located at the intersection of Routes 140 and 16 in Milford, Mass. A full-service, community and regional teaching hospital, Milford Regional is a 145-bed, non-profit, acute care facility, serving a region of 20+ towns.
View the Milford Regional Medical Center page in the 2017 Intalere Best Practices Compendium.