Reducing Readmission Risk Through Whole-Person Design

This case study outlines the efforts of Corewell Health to reduce hospital readmissions by implementing a whole-person design approach. The document describes the organization, a not-for-profit healthcare system, and its initiative aimed at improving patient outcomes following discharge. Corewell Health adopted the Scaled Agile Framework for Enterprises (SAFe®) to create cross-functional teams focused on patient care. By utilizing predictive analytics and patient indicators within their electronic medical record system, the teams identified high-risk patients and provided targeted support through care managers. The study details the challenges faced by patients, including social determinants of health, and emphasizes the importance of customized care. It also discusses the transition support model, which evolved from a single phone call to a more comprehensive approach addressing clinical, behavioral, and social health needs. The results showed a significant decrease in readmission rates, demonstrating the effectiveness of this innovative care model in enhancing patient recovery and reducing healthcare costs.