Back To Schedule
Tuesday, November 27 • 10:15am - 11:45am
A-16 - Reducing Hospital Readmissions: Methods, Process Evaluation, and Preliminary Outcomes

Sign up or log in to save this to your schedule, view media, leave feedback and see who's attending!

One in four HIV-positive individuals admitted to a hospital in southwestern Pennsylvania is readmitted within 30 days. Literature provides evidence that comprehensive primary care, including patient education and care management, can significantly reduce hospital readmissions. However, many HIV/AIDS providers find it challenging to find the time and resources to implement these best practices. This presentation will showcase how a Part C clinic reduced the rate of 30-day hospital readmissions through the adoption of Lean quality improvement strategies. It will also describe the FOCUS-PDSA model, low-tech intervention methods, process evaluation elements, and outcome measures associated with reducing hospital readmissions. Early results indicate the 30-day hospital readmission rate fell by more than 50 percent since implementation.

Learning Objectives:

  • Participants will learn how to adopt a robust system to follow-up with their patients while in the hospital to make up for common challenges related to the discharge of complex patients. They will learn the steps that the clinic implemented to effectively reach out to their hospitalized clients during and after hospitalization.
  • Participants will be introduced to the Lean process improvement methodology that has been successfully applied to wide variety of healthcare and social service settings around the country. Specifically, the HIV clinic at the heart of the program used concepts from this method to improve operations at the clinic that led to the reduction of 30-day hospital readmissions. Participants will participate in a Lean methodology training activity similar to one provided to the HIV clinic to introduce key concepts including unambiguous communication, workflow analysis and balancing, and process mapping.
  • The third objective of this Participants will learn how to investigate whether hospital readmissions among HIV- positive individuals are an issue in their region. In SWPA the research indicated that this was an important HIV/AIDS related health disparity, as the rate of 30-day hospital readmissions was more than 50 percent higher than that of the general population. This issue is at the confluence of the National HIV/AIDS strategy (as an HIV/AIDS health disparity) and the Affordable Care Act (as a cost containment and care coordination issue).


Judith Adams,R.N.

Admistrative Director, Positive Health Clinic

Jennifer Condel

Senior Quality Improvement Specialist, Pittsburgh Regional Health Initiative

Stuart Fisk

Clinical Manager, Positive Health Clinic

Sara Luby

Data and Quality Manager, Positive Health Clinic

Cindy Powers Magrini

Clinical Pharmacy Specialist, Positive Health Clinic
Cindy Powers Magrini, PharmD, BCPS is the pharmacist at the Positive Health Clinic (PHC) and comes to the PHC with experience in hospital clinical pharmacy. Prior to joining PHC, she was the outpatient pharmacy coordinator for the retail pharmacy located within Allegheny General Hospital... Read More →

Richard Smith

Program Manager, Jewish Healthcare Foundation
Richard Smith is a Project Manager for the Jewish Healthcare Foundation for the HIV/AIDS program. Mr. Smith has extensive experience in quality management as he has been the Continuous Quality Improvement Coordinator for Albert Einstein Medical Center HIV Clinic (part C) in Philadelphia... Read More →

Tuesday November 27, 2012 10:15am - 11:45am EST
Madison B

Attendees (0)