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Keys to Managing Transitions of Care

Joe Cantlupe, for HealthLeaders Media, May 23, 2013

Sarasota Memorial Healthcare System's focus on care transitions for its elderly and heart failure patient population has continually resulted in good readmission scores. Other hospital leaders could do the same, but the process has taken years and attention to detail.

In some ways, the Sarasota (FL) Memorial Healthcare System is already at the point where many of America's hospitals want to be. It has distinguished itself by caring for a significant elderly population for years, serving patients in a county that has the fourth-oldest residents in the country.

As more hospitals struggle to lower readmissions, Sarasota Memorial has been there, done that, despite caring for a challenging group of patients. Its 804-bed safety-net health care system's inpatient population is 50% Medicare, and it provides about 85% of local Medicaid hospital services. Yet the hospital achieved a 30-day readmission rate for heart attacks of 16.9% last year, compared a national rate of 20%, according to CMS data.

Getting there involved a "long and winding road" to improving quality, safety, and outcomes, says Fred D. Jung, RN, PhD, CPHQ, executive director of quality and patient safety.

One of the most significant and successful aspects of care for Sarasota Memorial has been its heart failure clinic. "If you look at it, we're comprehensively doing everything that everyone identifies as being significant [to improve care]," Jung says. Sarasota has been tracking its outcomes, costs, and efficiencies for years. "It wasn't 'wow, value-based purchasing is coming and there are going to be penalties for readmission rates.' We did this before people really thought about readmission rates," he says. Heart failure care has been a centerpiece and a focus for over a decade.

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