Many hospital readmissions occur simply because the patient and/or the patient's caregiver did not clearly understand
or comply with the original hospital discharge instructions. Whether the patient is transitioning from inpatient hospital care to a sub-acute
facility or to their home, this transition of care moves the patient from an environment in which their care was tightly managed to one with a high reliance on
Listen to pre-conference comments from Baratto and Berry.
During Best Practices in Hospital Discharge to Reduce Preventable Readmissions, a 90-minute webinar on CD-ROM,
two industry experts described how their organizations have fine-tuned their hospital discharge processes and the impact these steps have had on patient outcomes and satisfaction and readmission rates.
Nora Baratto, manager of the case management department at St. Peter's Hospital's CHOICES program, Albany, N.Y., and Michelle M. Berry, director of the Community Alternative Systems Agency (CASA) in Broome County, New York, provided the inside details on:
- Their organization's best practices in hospital discharge policies and procedures that have improved this transition in care;
- Using a community-oriented approach to an acute care mindset;
- Utilizing a patient/client-directed approach versus a system/silo-directed approach;
- Assessing and stratifying patients at discharge based on their risk level for readmission and assigning targeted interventions based on
- Enhancing the communication between providers and patients to improve results;
- Developing patient and caregiver education programs that lead to a clearly understood plan of care;
- Structuring follow-up phone calls and/or home visits to ensure patient compliance;
- Analyzing the impact of changes to hospital discharge procedures; and
- Special considerations for the elderly population during hospital discharge.
Available in three formats
- CD-ROM for computer play
- CD-ROM for stereo play
- On Demand version accessible online
Please note the stereo version ships as two CD-ROMs, whereas the .mp3 version ships as one CD-ROM.
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||Community partnerships are critical to the success of Albany's St. Peter's Hospital CHOICES program and its outreach toward the elderly, who tend to plan well for retirement and death but not always for the medical emergency that might occur in between those two life events, explains Nora Baratto, CHOICES case management department manager.|
Nora Baratto is the manager of St. Peterís Hospital case management and the CHOICES case management program. Prior to this she worked in long term care for six years.
Baratto received her masterís degree in Social Work with a concentration in Management from State University at Albany. She is a licensed clinical social worker (LCSW-R) and has her certification and accreditation in case management. Baratto is a member of the National Association of Geriatric Case Managers and American Case Management associations.
||Michelle Berry forsees that as the healthcare industry moves toward personal health records for all, the patient will eventually own his or her discharge plan.
Michelle Berry is the director of Broome County, N.Y., CASA. CASA is a central access and assessment agency for long-term care. CASA serves people of all ages and incomes in need of long-term care and authorizes Medicaid payment for a number of home care programs.
In 1996, Berry led the development of one of the first Nursing Home to Community Programs in the United States. This program was selected as a winner of the 2005 Livable Communities for All Ages competition sponsored by the Administration on Aging.
Berry has worked as a social worker in a nursing home, a hospital discharge planner and assistant director of Action for Older Persons, Inc. She currently serves on a number of advisory boards and as ex-officio Board President of the Family and Childrenís Society. Berry has also participated in numerous state sponsored work groups and currently serves as a member of the New York State sponsored Long-Term Care Restructuring Advisory Committee and is a member of the New York State Department of Healthís Discharge Planning Workgroup.
She is past president of the CASA Association of New York State; lectures twice a year at the Geriatric Scholarship Certificate Program sponsored by Columbia University and Upstate Medical University Office of Continuing Education; and serves as an adjunct instructor at Broome Community College teaching Human Services Organizations.
Berry holds a bachelorís degree in Sociology from Plattsburgh State College and a masterís in business administration from Binghamton University.