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Home>Disease Management
Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients
Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients
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The federal government's mandate to reduce costly hospital readmissions of Medicare patients, pending legislation such as the Medicare Care Transitions Act of 2009 and adoption of the care coordination-focused medical home model are forcing a closer look at the transitioning of patients between care sites — hospital to home, hospital to skilled nursing facility (SNF), SNF to home, and from one hospital department to another — and the opportunities they present to close gaps in care, eliminate medical errors and reduce healthcare costs.

Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients is an essential resource for healthcare organizations wishing to evaluate their care transition efforts against best practices in the industry. This 40-page resource delivers current trends in care transition programs as well as advice and guidance from industry thought leaders on key elements of care transition programs — from enhancements to the hospital discharge process to medication reconciliation ideas to better utilization of home visits during care transitions.

Part of the Reducing Hospital Readmissions Toolkit, a four-volume set with case studies from a variety of programs aimed at reducing unnecessary hospital readmissions, from discharge planning, transition coaching, transitions in care case management, medication reconciliation, community partnerships, home visits, assessments to identify high-risk patients and patient and caregiver education. Click here to save 25% when you order the Reducing Hospital Readmissions Toolkit.

Poor communication, conflicting information and medication errors during transitions in care contribute to rehospitalizations for Medicare beneficiaries, which accounted for $17.4 billion of the $102.6 billion Medicare paid hospitals in 2004, according to one estimate. Additionally, in an AARP study, one in five Americans 50 and older with at least one chronic condition and one hospitalization in the last three years said their transitional care was not well- coordinated.

This exclusive 40-page report analyzes the responses of nearly 100 organizations to HIN's April 2009 Industry Survey on Managing Care Transitions Across Sites, presenting the data in dozens of easy-to-follow graphs and tables. This industry snapshot is enhanced by recommendations and advice from thought leaders in care coordination as well as detailed case studies of successful care transitions programs:

  • Geisinger Health Plan's embedded case managers manage every Medicare patient through transitions in care — from hospital to home or from hospital to nursing home — as part of its lauded patient-centered medical home PCMH pilot program.
  • McLeod Regional Medical Center's use of a Universal Medication Form clarifies communication of medication information among patients, providers and pharmacists during patient transfers and discharges at the 453-bed flagship hospital.
  • Commander's Premier Consulting Organization recommends case manager adherence guidelines and a host of health literacy tools that can help bring about the behavior change necessary to improve medication adherence and self-management among elderly patients.
  • St. Peter's Hospital CHOICES program collaborates with community organizations to reduce readmissions, reduce avoidable hospitalizations and divert unnecessary ER care for its older patients.

Whether your organization is just beginning to examine transitions in care or is already getting results from care transition planning, the key to success is access to reliable program and performance data.

Get answers to the most common questions surrounding care transitions from suggested training for the transition team to program challenges and benefits to measuring the success of care transition efforts.

Data highlights include:

  • Top three care transitions addressed by responding organizations;
  • Sector-specific analysis of care transition efforts by hospitals, nursing homes, long-term care facilities and more;
  • The number one component of a care transition program in use by more than four-fifths of respondents;
  • Ideas to improve hospital discharge planning;
  • Seven top tasks that take place during home visits, as well as the frequency, duration and impact of home visits;
  • Optimal training programs for staff members charged with transition programs;
  • The impact of care transition programs on healthcare costs, health utilization, avoidable hospital admissions, health outcomes and caregivers and other benchmarks;
and much more.
Publication Date: August 28, 2009
Number of Pages: 40
ISBN 10: 1-934647-93-4 (Print version); 1-934647-94-2 (PDF version)
ISBN 13: 978-1-934647-93-6 (Print version); 978-1-934647-94-3 (PDF version)
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