west virginia success stories

WV Local Success Stories
Quality improvement endeavors can often feel overwhelming, but chances are, you can learn from the experiences that another physician, hospital or nursing home has had in a similar situation. Coupled with support from Quality Insights Quality Innovation Network, learning what has worked for others — and what didn't — is a valuable strategic planning component. 

We encourage you to read the success stories, contact us for more information, and also let us know if you have a Quality Insights' success storyto share.

Adding a Care Transitions Coordinator to the Staff Proves to be Key in Reducing Readmissions

Thomas Memorial Hospital, located in South Charleston, WV, is a general medical and surgical hospital with 215 beds.   Quality Insights began working with this hospital in 2012 to reduce admissions and readmissions in the Medicare fee-for-service patient population.
Quality Insights assisted the hospital with conducting a root cause analysis, and as a result, staff identified several key drivers of readmissions. Based on these findings, Melinda Hutchison, Director of Case Management at Thomas Memorial, determined that using a Case Manager as a Care Transitions Coordinator for high risk patients would improve the success of implementing interventions to improve care and reduce readmissions.
The hospital was then ready to pilot this new Care Transitions Coordinator role. Due to budget constraints, Hutchinson decided to use an experienced Case Manager, Teresa White, as part time Care Coordinator.
Quality Insights assisted in setting up evidence-based interventions and developed measures to monitor the success of the interventions over time. The intended long-term outcome was a reduction in readmissions within thirty days.
The evidence-based interventions put into place with assistance from Quality Insights included:
  • Case Managers must screen all patients for high risk of readmission.
  • The Care Transition Coordinator remains engaged with high risk patients for thirty days post discharge.
  • Engagement starts with a patient visit by the Care Transition Coordinator in the hospital.
  • The Care Transitions Coordinator makes follow-up phone calls are then made to reinforce discharge instructions, address medication regimen, and ensure that a primary care physician appointment is scheduled and kept. 
As a result of Quality Insights’ work with this hospital over the past four years, Thomas Memorial has seen a reduction in readmissions.  Furthermore, case management staff has used the data to show the efficacy of the intervention.  Consequently, the hospital has allocated the financial resources to hire a full time Care Transitions Coordinator.
“I feel providing that personal touch during a patient’s hospital stay, and then following them at home, has created a true continuum of care. Placing the emphasis on reducing our number of readmissions and increasing our patient satisfaction scores are goals we as a facility continually aspire to improve,” said White about the addition of the Care Transitions Coordinator to the hospital’s staff.
Quality Insights continues to work with this hospital to expand and spread interventions to other patient populations. “It is empowering to work with a hospital like Thomas Memorial which is focused on its patients and improving the quality of the care transition process,” said Biddy Smith, Quality Insights Care Coordination Project Coordinator.