To gauge root causes of readmissions, the committee analyzed a group of roughly 400 patients, examining charts and conducting multiple interviews.
The committee found "shockingly low rates of understanding," Horowitz said. Only 38% of patients understood their new medications and only 18% understood that some of their medications had been stopped.
"Readmissions were occurring, in part, we discovered, because of the ways we were instructing discharged patients," she said.
Also, the committee determined that only one-third of patients had follow-up appointments already scheduled upon hospital discharge, and 38% of discharge summaries were never sent to outside clinicians.
Starting with one unit of the hospital and focusing only on heart failure patients, and later scaling to the whole hospital, the committee revised patient education materials, implemented daily interdisciplinary rounds, and brought in a dedicated pharmacist to manage medication reconciliation for discharged patients.
Also, the hospital forged collaborative relationships and scheduled monthly meetings with skilled-nursing facilities, area agencies on aging, hospice providers and other community groups.
After seeing success in one unit, the committee focused its efforts on high-risk elderly patients throughout the hospital.
"Over time we managed to get readmission rates down," said Horowitz, adding that the readmission rate for high-risk elderly fell from 28% to 18%. The hospital also has seen drops in all-cause 30-day, 60-day and 90-day readmission rates.
Yale-New Haven also has seen its penalties decrease under the CMS' readmissions reduction program. In 2013, the hospital's penalty was 0.93%, just under the 1% maximum for that year. Yale-New Haven's penalty fell to 0.51% for 2014.