How a Hospital-Community Partnership Can Reduce Readmissions

Wadley Regional Medical Center (WRMC) in Texarkana, Texas, has been recognized many times over for its medical advancements. WRMC is an area leader in stroke care, uses cutting-edge technology to offer less-invasive surgical options and three-dimensional breast exams to both Texas and Arkansas residents. On the horizon: a new facility, which promises to provide even more state-of-the-art health care services.

Case Management Director Sara Endsley

“To reduce readmissions, hospitals must communicate with external health care providers to identify and overcome gaps in, or barriers to, patient care.”

If such continuous innovation is a guiding principle at WRMC, so, too, is continuous improvement. In 2022, WRMC’s case management director, Sara Endsley, found that its Medicare fee-for-service readmission rates were higher than the Steward Health Care system’s organizational goal. Endsley worked with the TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) to address the readmissions issue. The TMF QIN-QIO provided claims and community social determinants of health data, including hospital-specific data, which revealed gaps in care.

To examine that data more deeply, Endsley convened a multi-disciplinary team that included external health care providers, as well as WRMC’s chief executive officer and representatives from the cardiopulmonary, registration and medical records departments.

“We cannot work alone in reducing readmissions – it’s a community-wide responsibility,” Endsley stated. Other entities, such as skilled nursing facilities, comprehensive rehabilitation centers and home health companies, must also examine their practices. Are they doing enough to help keep discharged patients out of the hospital?


Getting to work

Initially, the team met twice a month and monitored electronic health records to track a patient’s care path and identify which of Texarkana’s health care providers contributed to driving up readmissions. Those providers were asked to meet with the WRMC team to show how they planned to reverse the trend. “Each time we did this, readmissions from that partner decreased. Holding our community providers accountable proved to be beneficial,” Endsley said.

Now that readmission rates are under control, the team meets quarterly. Endsley and her case management staff, however, see reducing readmissions as a daily responsibility. The Case Management department monitors electronic health records each day to identify potential readmits; the staff also monitors patients admitted to the emergency room. 

For their part, community partners welcomed the opportunity to assess and improve the health care services they provided. In examining a patient’s experience, external providers gained invaluable, specific information about how to intervene and continue the care patients need to avoid readmission.

Collaboration in action

Overcoming transportation barriers was among the strategies that stemmed from the readmissions committee meetings. The committee found that transportation prevented some patients—especially those who were wheelchair bound—from keeping their follow up appointments. Because many of Texarkana’s taxi companies could not accommodate patients with mobility issues, WRMC turned to Retreat Transportation Non-Emergent Transport to fill the gap. Specially equipped vehicles offered patients a safe ride from their homes to their primary care providers or other medical offices. If a patient reached out to Retreat multiple times, a company liaison contacted Endsley to establish the best care plan.

Endsley also encouraged patients to step up their game. She pointed hospital staff to patient-facing tools the TMF QIN-QIO developed to strengthen the patient education effort. For example, if WRMC admitted a patient for a heart failure event, hospital team members would share the TMF QIN-QIO’s Heart Failure Zone Tool (PDF) and the Heart Failure Toolkit (PDF) upon discharge to help patients better manage their chronic condition.

Positive results

WRMC’s approach to cutting readmission rates was successful. In the 12-month period studied, WRMC’s Medicare Cost Report all-cause readmission rates fell from 12.1% to 5.4%; the year-to-date comparison for the South Region shows that readmissions rates fell from 11.2% to 4.5%, well below Steward Health Care’s 9% goal.

Retreat Transportation Non-Emergent Transport
Retreat Transportation Non-Emergent Transport provides transportation to patients who require a wheelchair or other ambulatory services. Retreat works with home health providers, skilled nursing facilities and individual physician offices to prevent readmissions.

Another positive outcome: a stronger relationship between the Emergency and Case Management departments. These departments now work more closely together to monitor patients at a greater risk for readmission.

Beyond the numbers, all patients benefit when the entire health care team focuses on preventing readmissions. Studies show that it is stressful to patients when they must return to the hospital for the same condition; once there, they are at greater risk for hospital-acquired infections.

“Everybody benefits when hospital staff and community health care providers communicate and work together,” Endsley stated, adding that WRMC will continue to have readmissions meetings to ensure discharged patients get the support they need to stay healthy at home.