OSF deploys care transition program, reduces readmission rate from 29% to 9%

OSF HealthCare, a health system that serves Illinois and Michigan, had a big challenge: Managing the high rate of patient readmissions from hospitals to skilled nursing facilities and eventually to home care.

THE PROBLEM

This issue stemmed largely from gaps in continuous care during transitions between these settings. Patients discharged from hospitals often were readmitted due to complications that could have been prevented with better…