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Bill Ligas
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Swedish Covenant Health
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Aggressive Intervention Helps Chicago Hospital Drastically Lower Number of Patients Readmitted After Treatment

by Nick Przybyciel | Apr 24, 2014

In a city with one of the highest readmittance rates in the country, Swedish Covenant Hospital improves outcomes with innovative care transition program that targets at-risk patients

CHICAGO  (Jan. 7, 2014) – While Medicare data emerged this week revealing Chicago has more hospitals with higher-than-average patient readmission rates than any other city in the country, one community hospital is pioneering an aggressive intervention program that is enabling it to buck this trend. 

According to government statistics compiled between July 2011 and June 2012, Swedish Covenant Hospital was one of 19 Chicago hospitals with a Medicare patient readmittance rate higher than the national average of 16 percent within 30 days of a procedure. But following the implementation of a unique care transition program, this north side hospital decreased its rate to 14.25 percent during the first 10 months of 2013, the last period statistics are available from Medicare monitoring firm Telligen. 

“Reducing the number of patients readmitted after receiving treatment at Swedish Covenant Hospital is a top priority,” said Mark Newton, Swedish Covenant Hospital CEO. “Our nurses and physicians have taken the initiative to develop a remarkable post-discharge intervention that drives down health care costs while simultaneously improving the patient experience, resulting in a lower readmittance rate since implementation.”

A growing body of research suggests that helping newly-discharged patients better understand their conditions and medications, while providing them with the tools needed to manage their conditions, is crucial to preventing costly hospital readmissions. Focusing on patients with chronic conditions is necessary to lower this rate, as they account for the vast majority of readmittances. 

Currently, eight in 10 older adults in the U.S. are living with a chronic condition. This exacts a tremendous human and economic toll – three out of every four healthcare dollars spent are on chronic diseases and adults with these conditions account for 80 percent of all hospital days. 

While poor disease management often causes readmissions, chronic disease patients who experience rapid rehospitalization often do so as a result of other health complications. For example, a 2009 study found that for more than 60 percent of Medicare patients hospitalized for heart failure or COPD who experienced a readmission within 30 days, the cause of the readmission was something other than heart failure of COPD. 

To lower its readmittance rate, Swedish Covenant Hospital designed a care transition program unlike any other in the country, combining traditional home health services with sophisticated telehealth monitoring and electronic health records integration. This tiered program delivers a wide spectrum of services, including disease management coaching, home visits, telephonic follow-up care coordination, and, for those at highest risk, daily home telehealth monitoring. 

During the first ten months of 2013, Swedish Covenant Hospital’s care transition program has driven the following results:

  • Reduced the percentage of chronically ill patients readmitted at Swedish Covenant Hospital within 30 days following a procedure from 27 percent to 16 percent.
  • Contacted 1,800 patients in their homes, with hospital staff answering questions related to signs and symptoms or worsening health conditions or ineffective medications.
  • Nurse Wellness Coaches performed approximately 175 home visits, aiding patients with complex questions and needs. 
  • 88 percent of patients scheduled an appointment with their physician within 14 days of discharge.
Thanks in part to a $175,000 grant awarded by the G. A. Ackermann Memorial Fund, Swedish Covenant Hospital’s chronically ill patients will have access to an expanded care transition program in 2014 that includes additional services like nutrition screening and management. This component was added in response to research indicating malnourishment after discharge is a strong predictor of readmission.

Grant funding also enables the program to target vulnerable patients who are not covered for home health services because they’re not considered “home bound” by insurance providers. 

“Our program fills a gap in the current system of care because it specifically targets high risk patients who are either uninsured or do not meet the strict federal eligibility criteria to receive home health services,” said Kathryn Donofrio, Swedish Covenant Hospital associate vice president and nursing director. “Without these crucial services, these patients would fall through the cracks of the health care system and remain at higher risk of complications, dramatically impacting their quality of life.” 

As part of the program, all Swedish Covenant Hospital inpatients are screened for readmission risk before discharge. Those scoring above a risk cutoff receive an annotation in their EHRs and are then visited by a Wellness Coach (registered nurse) who assesses the patient’s ability to become an active collaborator in the management of his/her illness. Owing to the diverse ethnic and socioeconomic patient population served by Swedish Covenant Hospital, the program has a multi-lingual team (English, Spanish, Polish, Greek, Romanian and Tagalog) of Wellness Coaches who deliver linguistically and culturally competent care. 

Within two days of discharge, a home visit by a Wellness Coach provides care coordination, medication reconciliation and a nutrition screening. Follow-up telephone calls are then conducted throughout the patient’s recovery period. Those at need for additional support receive continued home visits, disease management coaching, telehealth monitoring via remote sensors and care management delivered over a three-month period.  

The care transition program is entirely funded through grant money and Swedish Covenant’s Hospital’s general account. 

Recent Media Coverage

NorthShore University HealthSystem to acquire Swedish Covenant Hospital on Chicago's North Side (Chicago Tribune, 6/27/2019)

Swedish Covenant plans to join NorthShore by the end of this year (Chicago Sun Times, 6/27/2019)

NorthShore agrees to buy Swedish Covenant (Crain's Chicago Business, 6/27/2019)

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20 Foods Doctors Always Avoid While Traveling (BestLife, 5/10/2018)

Drinking Study Suggests Alcohol Guidelines for Men Too Loose (PBS | WTTW, 4/18/2018)

She went to the ER for a rape exam. Her nurse didn't know how to do one. (Chicago Tribune, 3/28/2018)

The Girlfriend's Guide to Chemical Peels (The Girlfriend, 3/8/2018)

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Chicago Hospitals Could House Homeless Patients (Planetizen, 1/24/18)

Saving lives, saving money: Hospitals set up homeless patients with permanent housing (Hartford Courant, 1/15/2018) 

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Swedish cozies up to its heritage (Crain's Chicago Business, 1/5/2018)

Investing In The Lab: The Hidden Jewel In The Healthcare System (Forbes, 1/5/2018)

Nitrous Oxide Provides Pain-Relief During Childbirth (Chicago Health, 12/20/2017)

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NTI Interview - Pain Control: June Oliver, MSN, CNS (allnurses, 7/6/2017)

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Swedish Covenant Hospital completes phase 1 of 4 in ED renovation (Becker's Hospital Review, 6/13/2017)

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Swedish Covenant Hospital to Give Away Bike Helmets (Covenant Companion, 5/19/2017)

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Chicago hospital giving away 1,000 bike helmets (The Washington Times, 5/15/2017)

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5 Healthy Eating Tips to Get You Through Thanksgiving (Get Old, 11/20/2016)

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Swedish Covenant Medical Group Midwifery Practice Named Only "Triple Aim" Best Practice Group in Illinois (The Sounds, 9/24/2016)

AMT Member Spotlight: Isaias F. Torres, RMA (American Medical Technologists, September 2016)

Pure Oxygen Helps Wound Healing (Chicago Health, 8/15/2016)

New Swedish Covenant Hospital CEO Anthony Guaccio visits 30 floors in first 30 days (Becker's Hospital Review, 7/21/2016)

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Swedish Covenant Hospital Receives Get With The Guidelines-Stroke Gold Plus Quality Achievement Award (Public Now, 6/23/2016)

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5 safety-net hospitals, health systems to know, part 2 (Becker's Hospital Review, 5/20/2016)

Swedish Covenant Hospital Helps Raise Awareness for Stroke, the Leading Cause of Disability in the U.S. (noodls, 5/17/2016)

Art program helps Swedish Covenant cancer patients face their disease (Becker's Healthcare, May 16, 2016)

Moving psych patients through the ED: A new model features faster assessment, better safety (Today's Hospitalist, May 2016)

Swedish Covenant Hospital Gets 'A' for Safety (Covenant Companion, 5/3/3016)

Safest Hospitals in Illinois for 2016 (Reboot Illinois, 4/27/2016)

Safest Hospitals in Illinois: Report (Chicago Press Release Services, 4/27/2016)

Find out which Chicago hospitals are the safest (Crain's Chicago Business, 4/26/2016)

Leapfrog: 798 hospitals earn A scores for patient safety; See the list (Healthcare Finance, 4/25/2016)

Patient Safety Rankings: Best and Worst Illinois Hospitals (Naperville Patch, 4/25/2016)

Swedish Covenant Medical Group: About Darcie Trier (saignite, March 2016)

Why We Need Sleep (WGN-TV, March 21, 2016)

You are what you eat (Chicago Health Online, Spring 2016)

Hospitals raise awareness about managing heart disease during American Heart Month (AHA News, 2/18/2016)

Lincoln Square Lends Helping Hand to Families Displaced by Rogers Park Fire (DNAinfo, 1/20/2016)

Lincoln Square Food Pantry Donation (ABC 7 Eyewitness News, 1/8/2016)

EOS lip balm caused blisters, rash, lawsuit claims (Today Health & Wellness, 1/14/2016)

This Nurse Leader Cut LOS by 40% in the Emergency Department (Healthleaders Media, 1/12/2016)

Featured Buildings: Swedish Covenant Hospital (2015 Chicago Energy Benchmarking Report, Dec. 2015)

Swedish Covenant Hospital Earns Recertification as a NICHE Designated Hospital (The Sounds, 12/19/2015)

New Immediate Care Centers Improve Access to Quality Care (Healthleaders Media, Dec. 2015)

New Resource for Mental Health and Substance Abuse Treatment (The Chicago Doctor, Dec. 2015)

Swedish Covenant Hospital Gala: A Night for the Future (The Chicago Doctor, Dec 2015-Jan 2016)

Newton to step down as Swedish Covenant CEO, replaced by COO (Modern Health, 11/24/2015)

Swedish Covenant CEO to step down after 15 years at the helm (Crain's Chicago Business, 11/23/2015)

Swedish Covenant Hospital Once Again Recognized for Patient Safety (The Sounds, 11/21/2015)

Non-Surgical Treatment Helps Patients Suffering From Overactive Bladders (The Sounds, 11/7/2015)

Covenant Hospital Saves My Life, Again (Irish American News, 11/2015)

Swedish Covenant joins growing list of hospital urgent-care operators (Modern Healthcare, 7/27/15)

Health Insurance Shoppers Look to Limited Networks to Save Money (New York Times, 4/14/15)

Swedish Covenant's New Women's Health Center Breaks Down Barriers (DNAinfo, 10/2/2015) 

Swedish Covenant wants to dispense medical marijuana (Chicago Tribune, 7/21/14)

Cancer risk drives debate over hysterectomy tool (Chicago Tribune, 7/9/14)

Six months in, Obamacare impact on emergency room visits unclear (Sun-Times, 6/23/14)

Oral Cancer: Do You Know the Symptoms? (RadioMD, 4/7/2014)

Study Ranks Illinois’ Healthiest Counties (NBC Chicago, 3/27/2014)

Illinois deals with Medicaid application backlogs (Chicago Tribune, 3/24/2014)

Illinois hospitals shift to consumer convenience (Associated Press, 3/22/2014)

Affordable Care Act Press Conference featuring CEO Mark Newton (CAN TV, 3/18/2014)

ACA Enrollment Event Coverage (Univision, en espanol, 3/15/2014)

Swedish Covenant Hospital could benefit from 40th ward TIF district (DNAInfo, 3/10/2014)

Swedish Covenant Hospital hosts block party for healthcare enrollment (Lawndale News, 3/6/2014)

Obamacare signup push in 47th ward for ‘staggering’ number of uninsured (DNAInfo, 3/4/2014)

Advocate, Loyola among initial group to launch new Medicaid cost-saving initiative (Crain's Chicago Business, 3/3/2014)

A Glamorous Gala raises $815,000 for women's health (Pioneer Press, 2/10/2014)

Focusing on patients, not the condition: What hospitals need to know about avoiding Medicare readmission penalties (Becker’s Hospital Review, 2/5/2014)

Going grassroots: How Swedish Covenant Hospital is encouraging exchange enrollment (Becker’s Hospital Review, 1/17/2014)

Two Weeks Into Health Law's Rollout, Few Problems, Few Patients (The Wall Street Journal, 1/16/2014)

Health insurance enrollment surges in Illinois (Chicago Tribune, 1/14/2014)

A Look Inside the One of the Country's Safest Hospitals (Becker's, 1/10/2014)

3 more health insurers extend payment deadlines (Associated Press, 1/10/2014)

Executive Roundtable: What frustrates hospital CEOs, CIOs about health IT? (Becker’s Hospital Review, 1/10/2014)

Leapfrog Top Hospital Announcement (DNAInfo, 12/2/2013)

Back pain? A special sponge could help (WGN TV, 10/13/2013) 

Chicago doctors welcome Chinese girls with medical needs into their family (Chicago Tribune, 5/14/2013)



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