Excellence in Population Health
| Autor: | Nancy Phoenix Bittner, Amy A Lemieux, Cheryl Warren |
|---|---|
| Rok vydání: | 2019 |
| Předmět: |
Adult
Male Patient Transfer medicine.medical_specialty Leadership and Management Psychological intervention Pharmacist Pharmacy Population health Assessment and Diagnosis Community Networks Centers for Medicare and Medicaid Services U.S Cohort Studies 03 medical and health sciences 0302 clinical medicine Acute care Health care Humans Medicine 030212 general & internal medicine Community-based care Intersectoral Collaboration Care Planning Aged Quality of Health Care Aged 80 and over Population Health business.industry 030503 health policy & services Health Policy Middle Aged United States Models Organizational Family medicine Female 0305 other medical science business Medicaid |
| Zdroj: | Professional Case Management. 24:39-45 |
| ISSN: | 1932-8087 |
| DOI: | 10.1097/ncm.0000000000000303 |
| Popis: | Purpose/objective The Community-based Care Transitions Program (CCTP) defined a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission. The purposes for a CCTP as developed by the Centers for Medicare & Medicaid Services are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings. The goals for this CCTP initiative were as follows: achievement of a 20% reduction in the 30-day all-cause readmission rate across all partner hospitals compared with baseline; reduction in the 30-day all-cause readmission rate among the high-risk cohort served; and achievement of the target volumes for full enrollment. Primary practice settings The partnership included acute care institutions and community-based care organizations that have been involved with care transition programs for years and have a long history of working collaboratively to provide services to a largely low-income, underserved, and ethnically and racially diverse target population. Findings/conclusions The program successfully transitioned to full operation within the first year of inception. To date, the partnership of the acute hospital setting and the community-based organizations has reached and provided services to nearly 8,000 total individuals, surpassing our target enrollment goal. To date, the readmission rate has decreased to 12.5%, which is an 11% decline since inception of the program. Implications for case management practice The collaboration of health care providers, social workers, nurse practitioners, physicians, community pharmacists, and the visiting nurses is integral to a successful transition from hospital to home. Home visits by the transition facilitators allowed for the coordination of a multitude of services in the community, including those previously available to patients in the past that have rarely been accessed. Including a pharmacist on the team provided teaching regarding medication adherence, medication management, and pharmacy services, which added to interventions to decrease future hospitalizations. |
| Databáze: | OpenAIRE |
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