Improvements in Care-Transitions: A Case Study of St. Luke's Hospital

August 2013
This study focuses on four critical capabilities that were the cornerstones of St. Luke's Hospital's care redesign work.
Patient in rehab

The following is an introduction to the study, which focused on four critical capabilities that were the cornerstones of St. Luke's Hospital's care redesign work:

  • Cross-continuum participation and alignment;
  • The development and use of standardized tools and compatible information infrastructure;
  • Horizontal leadership and executive sponsorship; and
  • Effective external and internal learning.

The study also shares how St. Luke's Hospital translated those capabilities into effective programmatic action.

St. Luke's Hospital is a private hospital serving Cedar Rapids, Iowa, and surrounding suburbsSt. Luke's is part of the Iowa Health System, a non-profit corporation and the largest integrated health system in the Iowa/Western Illinois region. St. Luke's is recognized for its heart care, newborn intensive care, physical medicine, and rehabilitation and trauma care. It has also won several national distinctions as a healthcare leader.

Over the past decade, St. Luke's has developed an effective program to improve care-transitions and reduce preventable rehospitalizations. Since 2006, St. Luke's has been an active participant in the Institute for Healthcare Improvement's work on care transitions, including the State Action on Avoidable Rehospitalizations initiative and the Transforming Care at the Bedside Learning and Innovation Community.

Reducing Heart Patient Readmissions

Drawing on these programs and other resources, St. Luke's designed, implemented, and refined a comprehensive readmissions reduction initiative targeted at heart failure patients. The program spans the full continuum of care and includes enhanced admission assessments, real-time handover communications, patient education and discharge instructions, and post-acute care follow-up. The core of the program is the Cross-Continuum Team, whose members include a broad set of stakeholders responsible for reviewing readmissions, assessing causes and opportunities for improvement, and implementing programmatic interventions.

St. Luke's has been successful in reducing heart failure readmissions (for any cause) within 30 days of discharge from approximately 25 percent in 2006 to 15 percent in. St. Luke's has expanded its readmissions reduction initiative to heart failure, acute Myocardial Infarction, pneumonia, and chronic obstructive pulmonary disease.

The larger Iowa Health System has recognized St. Luke's success and has begun spreading readmissions reduction programs to all of its member hospitals. In 2010, the Clinical Counsel for the Iowa Health System identified reducing readmissions as one of three system-wide clinical initiatives. Reducing readmissions was important to Iowa Health System leaders because it aligned with the Health System's patient-centered ethos. The effort offered a vehicle to develop competencies in analytics and care redesign, which could then be leveraged to enable other value-based reforms.

Download the full Improvements in Care-Transitions: A Case Study of St. Luke's Hospital paper.


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