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Intalere Member Best Practice Spotlight: Crossing Rivers Health Navigating the C’s – Collaboration, Coordination and Continuity – to Reduce Readmissions

Crossing River Health

This post looks at how the implementation of an interdisciplinary readmission team at Crossing Rivers Health in Wisconsin helped dramatically reduce readmission rates.


Crossing Rivers Health was missing the consistency necessary to sustain a reduction in readmission rates. The facility’s goal was to enhance collaboration, coordination and continuity related to patient care transitions.


An interdisciplinary readmissions team was established to conduct an in-depth analysis of current processes and protocols to develop systems to close any identified gaps, and Lean principles were used to map out processes. The team integrated best practices to create a sustainable and replicable process to benefit all patients. A Nurse Navigator program was implemented which enhanced identification of moderate and high-risk patients, coordinated care after discharge and provided follow up with a home visit when needed. Follow-up phone calls within 24 hours of discharge and consistent patient education were also emphasized.


Crossing Rivers Health’s readmission rate for December 2013 was 12 percent. After implementing the Nurse Navigator program and evidence-based strategies, the average 2014 readmission rate was 7.5 percent. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for “Staff discussed needs after discharge” in 2013 was 90.5 percent and was 98.6 percent the last quarter of 2014. These innovative strategies provide a seamless transition process for the patients.

About Crossing Rivers Health

Crossing Rivers Health (CRH), a non-profit, 25-bed Critical Access Hospital, was established in 1957. CRH serves approximately 300 people per day and employs more than 330 healthcare professionals. CRH provides more than 60 services which fulfill the healthcare needs of the people across southwest Wisconsin and northeast Iowa.

Read more member success stories here to learn more best practices for your healthcare organization.