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Hospital Readmission Reduction Project

Date of latest update

September 2014


rnes-Jewish Hospital at Washington University Medical Center, St. Louis, Mo.

For More Information Contact

Mark L. Corley, general manager (

Population Served

Elderly patients admitted for pneumonia, COPD, CHF or acute MI who are screened for high risk potential for readmission defined as having a LACE score of 10 or greater (PMCID: PMC 2845681) who do not qualify for, or refuse, home health services.

The Need

Hospitals face growing scrutiny from payers and governmental oversight bodies regarding hospital readmission rates for key diagnoses. Abbott EMS recognized that it could play a vital role in assisting local hospitals with focused patient populations deemed at risk for hospital readmission but who refuse home health or do not qualify for home health visits.

The Goal

To provide personalized and goal-directed care for patients who are discharged from the hospital with pneumonia, COPD, CHF or acute MI by working with hospital case management teams to specifically identify patient needs for disease education, outpatient clinic visits, transport planning, and empowerment for understanding and managing their chronic conditions to lessen their chances of acute exacerbations leading to readmission within 30 days.

Medical Oversight

The medical director for Abbott EMS, David K. Tan, M.D., serves as the program’s medical director. Rob Hackleman, a Stay Healthy Outpatient Program (SHOP) social worker, leads the hospital screening process and is involved in patient selection and operational quality assurance and quality improvement, giving direct feedback to the medical director. Protocol checklists and patient feedback go directly to SHOP and the patient’s chart.

Key Partners

Barnes-Jewish Hospital, Stay Healthy Outpatient Clinic


Six advanced practice paramedics


This pilot program is a shared risk model between Abbott EMS and Barnes-Jewish Hospital. Future funding will depend largely on the overall success of the program, in addition to value-added benefits realized by both parties.

Plans for Sustainability

Develop a sustainable fee structure using demonstrated cost savings to the hospital.

Technology Used

The CAD system in our current infrastructure is able to keep track of resources sent to the enrolled patients who are flagged in the system as part of the Hospital Readmission Reduction Project. The patients are also given a special number to call 24 hours a day,seven days a week should they feel the need to discuss a problem with their assigned primary care paramedic. The number is identifiable by the dispatcher that the caller is part of this program.

Program Results

This pilot program has a goal of 100 patients to enroll for data analysis. Currently,24 patients have been enrolled.

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Mobile Integrated Healthcare Practice

Funded in part by Medtronic Philanthropy.

Produced in cooperation with the RedFlash Group.