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Home>HIN Case Studies
5 Best Practice Prevention Protocols for Reducing Readmissions
5 Best Practice Prevention Protocols for Reducing Readmissions
5 Best Practice Prevention Protocols for Reducing Readmissions
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One in four Medicare patients discharged from nursing homes returns to the hospital or ER within 30 days, according to 2014 data from the University of North Carolina at Chapel Hill School of Nursing.

To reverse this trend, post-acute partnerships with skilled nursing facilities, home health and hospice are proving effective at reducing hospital readmissions, say two-thirds of respondents to HIN's 2013 Reducing Hospital Readmissions survey.

Demonstrating the benefits of these alliances, 5 Best Practice Prevention Protocols for Reducing Readmissions highlights Torrance Memorial Health System's network of SNFs and home health — part of its award-winning five-pronged approach to curbing rehospitalizations.

In this 30-page special report, Josh Luke, Ph.D., FACHE, vice president of post-acute services at Torrance Memorial Health System, highlights the five key initiatives that comprise his organization's Total Wellness Torrance (TWT) readmission prevention program.

Rounding out the TWT program is a readmission prevention manager, a post-acute clinic for follow-up, strategic use of risk stratification software and targeted messaging with a focus on patient choice.

Launched in early 2013, TWT has already been recognized as a Program of Excellence by the California Association of Healthcare Facilities, the state's nursing home trade organization, for its innovation and impact on the community.

Luke, who also founded the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shares the key features of TWT and its impact on readmission rates.

5 Best Practice Prevention Protocols for Reducing Readmissions also presents metrics in post-acute partnerships from the 2013 Reducing Hospital Readmissions benchmarks survey.

This report covers the following:

  • How to develop a Transitional Care program with an integrated post-acute network;
  • How to honor patient choice when developing an integrated post-acute network of preferred providers;
  • The role of a post-acute clinic in reducing readmissions; and
  • Protocols, processes and strategies in developing an effective partnership with skilled nursing facilities to reduce readmissions.

Table of Contents

  • Navigating Care Transitions with Preferred SNF and Home Health Providers
    • Role of the Readmission Prevention Manager
    • TWTs Post-Acute Network
    • Preferred Providers and Patient Choice
    • Coordinated Care Center Follow-Up Clinic
    • Risk Stratification Software
    • Secondary SNF Providers
    • Next Steps in Readmission Prevention Protocols
    • Lessons Learned from TWT
  • 2013 Benchmarks in Post-Acute Partnerships
    • Current Partnerships with Post-Acute Care
    • Most Common Post-Acute Partnerships
    • Lessons Learned from Post-Acute Partnerships
  • Q&A: Ask the Experts
    • Background of the Readmissions Prevention Manager
    • Challenges of Developing a Post-Acute Network
    • Home Visits and Care Transitions
    • Meeting Palliative Care Needs of Patients
    • Remote Monitoring Post-Discharge
    • Medication Adherence and Reconciliation
    • Reacting to CMS Readmissions Penalties
    • Origins of SNF Network
    • Challenges of Communications and Continuity
    • Benefits of Post-Acute Networks
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: March 2014
Number of Pages: 30
ISBN 10: 1-941329-02-0 (Print version); 1-941329-03-9 (PDF version)
ISBN 13: 978-1-941329-02-3 (Print version); 978-1-941329-03-0 (PDF version)
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