Reduce readmissions among chronically ill patients with post-acute care plan

Hospitals and health systems can reduce readmissions and improve quality of care by implementing a post-acute care model for patients with chronic diseases, Patty Upham, director of care transitions with FirstHealth of the Carolinas in Pinehurst, North Carolina, told Senior Writer Paul Barr in an interview for Hospitals & Health Networks.

The model takes a four-pronged approach to closing the gaps in post-acute care, which the program identified since its inception in 2009:

  • Home healthcare. This aspect of the program provides care to chronically ill patients who qualify for home healthcare through Medicare. Partnerships with hospitals and heart centers play a huge role in the program, which has led to a reduction in readmissions among home healthcare patients from 26 percent in 2011 to 17 percent today, while emergency department use is also down, Upham said. Chronically ill patients in the program also reported a 25 percent increase in perception of quality of life.

  • Complex care-management program. For patients who aren't eligible for home health but still require ongoing supervision and management, Upham said the organization is piloting a new telehealth initiative that would provide information directly to caregivers' smart phones, and allow physicians to video chat with them. FirstHealth of the Carolinas wants to provide complex care management to uninsured populations using this technology.

  • Center for telehealth. This aspect of the program provides remote monitoring for high-risk heart patients in home health and complex-care management settings. The program helps patients who would otherwise be in a long-term care facility.

  • Care transition nurses. These specially trained nurses are imbedded in different areas of the care continuum to promote ongoing education and support for patients and caregivers throughout the healthcare delivery process.

However, with so many entities working together, Uptain saqid communication and establishing common goals is essential to success and improved results. "When you put the patient at the center of what you're trying to do that's really a good starting point so you can all come to a decision of how you're going to proceed," Upham told Barr.

To learn more:
- here's the video interview

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