Sep 282011

A three-part protocol, involving standardized assessment, palliative care consultations, and root cause analysis led to a 20% reduction in hospital readmissions for elderly skilled nursing facility residents, according to the AHRQ Health Care Innovations Exchange.

Led by Dr. Randi Berkowitz, a Practice Change Fellow, the initiative focused on reducing the risk of hospital readmissions at Hebrew SeniorLife,  an integrated eight-site system of health care, housing, research, and teaching based in Boston. The Practice Change Fellows Program [now the Practice Change Leaders for Aging and Health Program] is a two-year award that enables clinicians to work on projects to improve care of older adults, supporting them as they develop leadership skills and content expertise.

According to AHRQ, Berkowitz developed a program that featured: standardized assessment at admission to identify patients with multiple prior hospitalizations, palliative care consults and care plans for those who had had three or more hospitalizations in the previous six months, and a multidisciplinary staff conference to examine the root causes of inpatient readmissions when they occurred. As a result, inpatient readmissions decreased by 20%, from 16.5% before implementation to 13.3% after it.

Developing the project required that Berkowitz obtain approval from Hebrew SeniorLife leaders, form and advisory committee, develop the standardized admissions template, and introduce program and multidisciplinary conferences.  Learn more about the work at

Key Words: readmissions, palliative care consults, skilled nursing facility, care transitions