Reduce readmissions by giving transitional care a personal touch

Three nonprofit hospitals in the Bronx, N.Y. significantly dropped readmission rates thanks to personal contact with patients before and after discharge, according to study results released Wednesday by Montefiore Medical Center.

In addition to Montefiore, the Bronx Collaborative includes Bronx Lebanon Hospital Center and St. Barnabas Hospital, as well as insurers EmblemHealth and Healthfirst.

The collaborative handles the hospital-to-home transition and uses predictive modeling to select patients most likely to readmit. The group offered participants, Bronx residents age 50 and older, with a working telephone, as well as four interventions while in the hospital and for 60 days post-discharge.

Nurse care transition managers provided personal contact by holding a pre-discharge education session, scheduling a follow-up visit with the patient's physician, and making post-discharge phones calls to discuss medications and verify the follow-up visit took place, according to the research announcement.

Of the 500 patients who received two or more personal contact interventions, only 17.6 percent bounced back to the hospital within 60 days of discharge, compared to 26.3 percent of 190 patients who received standard care.

The results also showed that completing a follow-up physician visit within 14 days of leaving the hospital helps reduce readmissions.

At full scale, the Bronx Collaborative could reach roughly 9,300 patients at high risk of readmission each year and save $5.5 million, according to the New York State Health Foundation, which awarded nearly $575,000 to Montefiore Care Management to develop the transitional care interventions.

To learn more:
- read the research announcement
- here's the NYS Health Foundation info

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