Care transition program nets big drop in readmissions

NEWS IN BRIEF — Posted July 15, 2013

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A collaborative program among three nonprofit health care organizations in Bronx, N.Y., employed intensive pre- and postdischarge interventions to cut readmission rates by 33%. Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center worked together on the care transition program, which targets patients 50 and older with predischarge educational sessions that include detailed discharge instructions, a medication record and a list of symptoms to watch for at home.

The program also includes a postdischarge call within two to three days to identify concerns the patient or caregiver may have, review symptoms and medications, and verify a follow-up physician appointment within the next two weeks. Another call comes within 14 days to check in and confirm the doctor visit occurred. Nurses made further follow-up calls between 15 and 60 days postdischarge.

“These results underscore the value of personal contact with patients before and after their discharge from the hospital and follow-up appointments with their personal physicians to help prevent problems that frequently contribute to readmissions,” said Anne Meara, RN, a Montefiore executive who led the collaborative project’s design team.

The 60-day readmission rate was 17.6% among the 500 patients who received the extra pre- and postdischarge attention, compared with a rate of 26.3% for a comparison group of 190 patients who got the usual care. The results were presented in June at a meeting of the Case Management Society of America in New Orleans. The society awarded the program its annual Research Award.

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