19 Initiate compassion transition huddles to decrease readmissions

<h3>Description</h3> For many years our hospital has been working on reducing readmissions. We identified that we had a lot of projects and resources on improving these 30-day readmissions and we needed to work and communicate together rather than work in silos. We needed to identify Social Determinants of Health (SDOH), review Transitions Care Management (TCM) process and implement a Compassion Transition Huddles for complex discharges. Implementing SDOH on the inpatient units in April 2023, helped us identify which SDOH was prevalent in readmissions. We completed a review of patients who were not readmitted and reviewed their SDOH and found that these patients had great social connections. Patients readmitted had lower social connections, more isolated and had lower physical activity. We needed to ascertain how we are doing TCM appointments and phone calls and create reports. By identifying expectations earlier, this allowed for better coordination in rounding process. We standardized patient education in teach-back, beginning teaching at admission vs discharge. Since we have implemented Compassion Transition Huddle none of these patients were readmitted within 30 days. Our 30-day All Cause Readmission data in January 2021 was 9.84%, down to 6.25% in December 2023 (figures 1 and 2).