Transitional Care an Emerging Care Coordination Option

Keeping the beds empty is the goal!

Under the Hospital Readmissions Reduction Program, in fiscal year 2013, hospitals will be penalized by 1 percent for high readmission rates, increasing to two percent in 2014, and three percent in 2015.

In Atlanta, Gwinnett Medical and WellStar Health System use transition coaches to help guide patients through discharge and follow up. A transition coach may go with the patient to a doctor visit and follow up with calls. In addition, patients receive their personal health records and can call coaches with questions after they leave the hospital. Nursing facilities are partnering in care coordination to keep patients from re-hospitalization.

Signature HealthCARE launched a pilot program, TransitionalCARE, focusing on care between hospitals and nursing facilities, as well as from nursing facilities to the home. The program has seen the number of patients readmitted to hospitals within 30 days fall from 28 percent to 13 percent since March, 2010.

Three transitional coaches provide six coaching sessions during the patient's stay, helping them understand their diagnosis and medications to help manage their own health.

Hospital re-admissions are a problem for nursing homes because as they partner in ACOs with hospitals they too will be at financial risk.

More importantly is the growing realization that alternative therapies such as palliative care and patient education are keys to reducing re-admissions, maintaining quality of life and keeping people healthy.

Patient education can lead to:

• improved understanding of medical condition, diagnosis, disease, or disability
• Improved understanding of methods and means to manage multiple aspects of medical condition
• improved self advocacy in deciding to act both independently from medical providers and in interdependence with them.
• increased compliance
• better patient outcomes
• informed consent that puts the patient more at ease
• more effective use of medical services
• satisfaction and referrals
• lower risk of malpractice when patients have realistic expectations

How are you ramping up your patient education efforts?

Learn more ~ or join the conversation!

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Noel Hendrickson