Author(s): Jenny Bernard, DNP, MBA, MSN, APN-BC
Director of Community Health Quality Improvement
HMH

Competency Domain: Patient Safety

Description: Learning Approach: Process Improvement Problem Statement: How effective is the First Thirty program at reducing readmissions for high-needs maternal health patients? Methodology: The FT team implemented a bundle, leveraging Lean Six Sigma and Agile principles to ensure seamless care coordination tailored to individual needs. Implementation: The FT program collaborated with community partners to address patients' SDOH, including housing, food, transportation, and mental health support.Results: Community support (15,140 calls/1,321 transportations) led to 100% appointment scheduling and 73% attendance (77% of participants). Readmissions dropped from 7% (2022) to 2% (2023) and 1.6% (2024).