Reduce 30-Day Readmissions Without New Logins
Reduce 30-day readmissions without new logins
TL;DR
- Outcome-first in the EHR beats new portals. Embed a simple post-discharge workflow inside Epic/Cerner instead of adding another login.
- Qualified evidence: The Care Transitions Intervention (CTI) randomized trial reported lower rehospitalization at 30, 90, and 180 days in Medicare patients (PubMed).
- Burden reduction: Vendor-reported RPM→EHR integration was associated with less clinician call time and lower cost per patient (case example: Validic).
- Primary CTA: Download the Evidence Brief • Secondary: See the Epic/Cerner workflow one-pager
Context: the week-2 adoption cliff
Care-management programs often launch strong, then adoption dips by week two when clinicians hit extra logins or duplicate documentation. The work doesn’t fit the day.
“We captured … more than 2.5 million unique alarms in 31 days in our ICUs.” — Barbara Drew, RN, PhD, UCSF (on alarm fatigue)
“Clinicians described tremendous barriers to adoption … and stressed integrating tools with existing EMR systems and an easy-to-navigate interface.” — Qualitative study of EMR-integrated CDS (2025)
Problem: tools outside the workflow stall outcomes
- Alert fatigue dulls attention. Primary-care clinicians can receive 100+ alerts/day; many are low value, leading to overrides (AHRQ PSNet).
- Switching costs are real. Toggling to a separate app to manage post-discharge tasks adds clicks when time matters most.
- Adoption erodes without fit. Qualitative studies repeatedly cite workflow fit as a prerequisite for sustained use (override data; integration emphasis).
Solution: embed an outcome-first “hero” in the EHR
Goal: fewer 30-day readmissions via timely follow-up — without adding a new login.
- Discharge signal: Auto-flag high-risk discharges into the care-manager’s existing Epic/Cerner worklist (no new credentials).
- Action prompt: Present a 48-hour contact checklist (meds review, red-flags coaching, appointment scheduling) inside the plan-of-care note.
- Close the loop: Track completion in EHR audit and surface the next due step (call, televisit, home BP check) within the same screen.
Proof strip (qualified)
| Intervention | Observed impact | Source & methods |
|---|---|---|
| Care Transitions Intervention (CTI) | Lower rehospitalization at 30, 90, 180 days (Medicare) | Randomized controlled trial; PubMed • JAMA Intern Med |
| RPM→EHR integration | Less clinician call time; lower cost/patient/month | Vendor case report; Validic |
Notes: CTI is a patient coaching model with structured follow-up; the RPM example is vendor-reported and should be validated locally before claims.
How it lives in Epic/Cerner (no new logins)
- Where: Care-manager worklist + discharge navigator + plan-of-care templates.
- Ownership: Care-management lead + nurse informaticist partner with IT to configure flags/flowsheets.
- Security: All actions remain within existing EHR auth; no PHI exits the environment. See Security & Compliance.
Implementation: ownership, staffing, change management
Ownership
- Clinical champion: CMIO/CNIO or care-management lead to steer build and frontline testing.
- Governance: Quick weekly huddles during pilot to review flags→actions→outcomes (keep config nimble).
Staffing
- Use existing roles: Transitions coaches/care managers run the play; no net-new headcount.
- Data feed (optional): If RPM exists, surface trends in the same dashboard (not a separate portal).
Change management
- Train in 15-minute micro-sessions; emphasize “this lives where you already work.”
- Instrument early: measure flag visibility, click-through, contact completion.
- Iterate wording/placement to minimize cognitive load; prune low-value alerts.
What to measure
- Process: % of high-risk discharges reached within 48 hours; % with meds reconciliation done.
- Outcome: 30-day readmission rate vs. pre-pilot baseline (rolling 3-month average).
- ROI triggers: minutes saved per patient; avoided HRRP penalties (directional); vendor-reported cost offsets validated locally.
Frontline buy-in — 7 quick checks
| Check | Pass? |
|---|---|
| Appears on existing care-manager dashboard/worklist | ☐ |
| Auto-flags high-risk discharges (no manual hunting) | ☐ |
| Prompts clear next step (call, televisit, appointment) | ☐ |
| No additional login or password required | ☐ |
| Audit trail captures action & completion | ☐ |
| Inline tip sheet (< 2 min to read) | ☐ |
| Weekly review trims low-value alerts | ☐ |
Next step
Download the 3-minute Evidence Brief See the Epic/Cerner workflow PDF
FAQ
Do we need to buy new software?
No. This pattern uses native Epic/Cerner configuration. Keep it inside existing authentication.
What results should we expect?
In the CTI RCT, rehospitalizations were lower at 30/90/180 days in Medicare patients. Your impact will vary; validate locally before claims.
Will this add to clinician workload?
Designed to reduce switching and alerts. Qualitative evidence shows adoption depends on workflow fit and simplicity.
Epic and Cerner support?
Yes. Both support flags, worklists, templates, and audit without third-party portals.
References & Methods
- Coleman EA et al. Care Transitions Intervention RCT (2006) — randomized, Medicare patients; lower rehospitalization at 30/90/180 days.
- JAMA Internal Medicine full text — trial details.
- AHRQ PSNet — Alert fatigue primer — alert volumes and overrides.
- AHRQ PSNet — Alarm fatigue perspective (UCSF) — “2.5M alarms” quote.
- Passive EHR alert frequency & overrides — override rates and volume.
- Validic RPM→EHR — vendor-reported time/cost impacts.
- CMS HRRP overview — payment link to readmissions.