Project Information

Reduce Readmissions from Shands Rehabilitation Hospital

Project Description: Readmissions among patients discharged to rehab facilities often make up the majority of readmission cases, as is the case in neuromedicine at UF Health. Among the neuromedicine patients discharged to Shands Rehabilitation Hospital (SRH) in 2016, 69% of patients were readmitted to Shands Hospital, and 31% of those patients were returned back to SRH. Initial analysis shows that 90% of the time patients are transferred back to the Hospital, the neuromedicine provider who discharged the patient was not contacted. Furthermore, 70% of these returns occurred Monday-Friday, 7AM-5PM, not during after hour periods or weekends. All non-urgent case transfers should include a call to the neuromedicine provider before the transfer process is started, which is not being done for the majority of cases. This project will focus on the rate of communication between SRH staff and neuromedicine providers and will work to develop ways to increase these rate and in turn reduce unnecessary transfers. The transfer center process and SRH procedures are being analyzed to determine which method of improvement will best suit this project's goals. It is most likely that a pre-transfer checklist will be implemented to increase communication rates.

QPI: Hannah, Fulmer, (

Collaborators: Daniel, Hoh, (; Katharina, Busl, (

Advisors: Jacqueline, Baron Lee, (

UF Health Big Aims: Increase Value None

MeSH Keywords: