Each year in the United States, thousands of people are readmitted within 30 days of being discharged from a hospital. Current research indicates that at least one-third of these rehospitalizations are preventable. The purpose of this project was to examine patient and environmental characteristics of those who were readmitted within 30 days of discharge for commonalities that may explain the gap in practice for a specific health care organization. The project was undertaken in response to the organization's need to improve a 50th-percentile ranking with the goal of reaching the top 10th percentile. A plan-do study-act framework was used as a guide to ensure no steps in the process were missed and the logical progression of the project was clear. Three fiscal quarters of data, including 515 readmissions, were examined. A data analytics cube on hospital-wide readmissions provided patient and environmental characteristics that were charted using common language for sorting purposes. Data analysis revealed that 77% of patients were admitted within 30 days of discharge with a diagnosis that differed significantly from the index admission. Potential gaps in practice identified were a need for more patient and family engagement and education by nursing during the inpatient stay in regard to the primary admitting condition, the management of comorbidities, and potential posthospital complications. Need exists for more intense whole-patient monitoring, communication, and education following the transition from hospital to home. A reduction in 30-day readmissions can reduce the psychological and physical burden on patients and families, on health care resources that could be used for other purposes, and on society in the form of financial costs that continue to rise.

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Abstract Identifying Data Needs to Support the Public Health Program of First Care Background: First Care (FC) is a Georgia (GA) public health (PH) program funded by Title V Block Grant, whose main purpose is to provide collaborative skilled PH services for infants with LBW and VLBW (low and very low birth weight) as well as those considered at high risk for illness and disabilities. Purpose: 1. Describe current health outcomes of GA infants less than one years of age. * Current baselines of IMR (infant mortality rate), preterm, very low birth weight (VLBW) and low birth weight (LBW) births 2. Use data to inform FC program in order to improve overall health outcomes in LBW, VLBW and preterm infants less than 1 years of age in GA as well as IMR. * Identifying common diagnoses and reasons for the hospitalization of infants less than one. Methods: Several online secondary data sources containing GA birth outcomes were evaluated. These sources were used to produce most current or 2008, GA and national profiles on health outcomes such as IMR, preterm, LBW and VLBW births. SAS was used to evaluate OHIP (Office of Health Information and Policy) hospital discharges in 2008 to determine common diagnosis affecting GA children under 1 years of age. Results: National comparisons of health outcomes revealed that GA consistently ranks below the national average for IMR, preterm, VLBW, and LBW births. GA’s poor health outcomes are also seen when compared to Healthy People 2010 objectives. A comparison of GA public health districts (PHD) health outcomes demonstrates lagging indicators mainly in the southern and midsection (central section) of GA. This study also revealed racial disparities indicating Blacks falling behind in all health outcomes when compared to Whites and Hispanics. Statistical analysis of hospital discharges showed that the top 25 discharges reflect common conditions that affect high-risk infants such as preterm, VLBW and LBW infants. Higher rates of morbidity were found in the southern and central PHDs of GA. Conclusion: The purpose for FC is to provide current data baselines on health outcomes of GA infants less than one year of age, as well as information regarding current hospitalizations. Current results are only preliminary findings underscoring the need for continued research. By emphasizing their need for monitoring will allow FC to focus on this critical role that will only grow with an expanding population in GA.