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Transitions from the hospital go smoother and patients are less likely to be readmitted when the providers at the next level of care get detailed and complete information about the patient, says Sandy Merlino, RN, MBA, vice president, integrated delivery systems and hospital market development for Visiting Nurse Service of New York.
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Patients discharged from an acute care hospital to an acute rehabilitation facility are more likely to be readmitted to the hospital within 30 days if they score poorly on the Functional Independence Measure (FIM) test, which measures a persons ability to perform activities of daily living, according to a study at Johns Hopkins Medicine.
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Carondelet Health Network and the Pima Council on Aging have partnered to provide follow-up care coordination for at-risk patients who are being discharged from the hospital.
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As part of its efforts to decrease readmissions, OSF Saint Francis Medical Center in Peoria, IL, developed a hospitalwide initiative to create safe transitions.
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The CMS efficiency measure has once again raised the issues of length of stay management and cost reduction. These have always been a component of the role of the hospital-based case manager. In todays best practice models, these interventions must be correlated with the roles of coordination and facilitation of care, discharge planning and utilization management. The case managers roles and functions, as well as staffing ratios, must be designed in such a way as to allow for this integration of roles. Be sure that your department is focusing on how to embed this important function in your everyday practice!
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The Affordable Care Act and other provisions of healthcare reform definitely have shone a bright light on utilization, care coordination, and case management interventions.
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Eliminating distractions and standardizing the process for patient handoffs has helped a group of childrens hospitals reduce handoff errors by 69%.
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As penalties rise for readmissions, it is critical for hospitals to implement and support continuity of care initiatives as patients transition from one level of care to another.
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Lakewood Hospitals pilot project in which a patient navigator worked with at-risk patients saved the hospital $156,000 in just six months.
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The researchers who studied patient handoffs at 23 childrens hospitals found an alarmingly high baseline rate of handoff failure: 25.8% of the handoffs were insufficient or inaccurate.
