Open Forum

Hello everyone,

I am a Director of Ambulatory Nursing at an academic medical center and am currently leading a performance improvement project focused on reducing hospital readmissions.

One of our primary goals is to ensure that patients identified as high risk for readmission are scheduled for and complete a follow-up appointment within 7 days of hospital discharge. We are exploring workflows, care coordination strategies, and interventions that can improve timely access to post-discharge care and ultimately reduce readmissions.

I would be interested in learning:

• Are your ambulatory clinics involved in readmission reduction initiatives?
• How are you identifying patients at high risk for readmission?
• What processes do you have in place to ensure follow-up visits occur within 7 days of discharge?
• Are you utilizing nurse navigators, care coordinators, pharmacists, telehealth visits, or other interventions?
• Have you seen measurable improvements in readmission rates or other outcomes?

If your organization is doing work in this area, I would greatly appreciate the opportunity to connect and discuss lessons learned, barriers, and successful strategies.

Thank you in advance for sharing your experiences.