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Mission Hospital in Asheville, NC, has teamed up with seven employers in the community to provide face-to-face disease management for chronically ill employees.
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Whether patients are being discharged from the hospital to home, another level of care, or transferred to the care of another health care provider, communication is crucial to ensure a safe discharge or transition, says Hussein Tahan, DNSc, MSN, RN, CNA, executive director, international health services at New York Presbyterian Hospital in New York City.
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When patients don't follow their discharge instructions and end up back in the hospital, it may be that they simply don't understand what they were supposed to do at home.
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By working closely with a carefully chosen network of skilled nursing facilities, The Methodist Hospital in Houston has smoothed the transitions in care for patients being discharged to the facilities.
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Carondelet Health Network and the Pima Council on Aging have partnered to provide follow-up care coordination for at-risk patients who are being discharged from the hospital.
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Patients discharged from an acute care hospital to an acute rehabilitation facility are more likely to be readmitted to the hospital within 30 days if they score poorly on the Functional Independence Measure (FIM) test, which measures a persons ability to perform activities of daily living, according to a study at Johns Hopkins Medicine.
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Transitions from the hospital go smoother and patients are less likely to be readmitted when the providers at the next level of care get detailed and complete information about the patient, says Sandy Merlino, RN, MBA, vice president, integrated delivery systems and hospital market development for Visiting Nurse Service of New York.
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A team effort at Holzer Health System helped reduce the rate of all-cause readmissions by 20%.
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1. Look beyond the data.
2. Consult the palliative care team.
3. Reach out to embedded case managers.
4. Facilitate early discharges.
5. Follow up with assisted living residents.
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More hospitals than ever before are being penalized by the Centers for Medicare & Medicaid Services for excess readmissions and insurers are starting to develop their own readmission reduction programs.