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Keys to Managing Transitions of Care

Joe Cantlupe, for HealthLeaders Media, May 23, 2013

Sarasota Memorial got a head start years ago by putting structures in place to improve patient care transitions, Jung says. He characterizes his hospital's traditionally lower readmission rates as the result of a "combined, synergistic effect" from the success of multiple strategies built into the system over time.

"It's a given throughout healthcare—and physicians know this particularly well—that putting patients first is the way to go," Jung says. But how exactly is that done? Jung highlights managing care transitions after patient discharge, focusing on readmissions, and yes, keeping an eye out for regulations and penalties.

As Sarasota Memorial embarked on its path to better quality, establishing a strong electronic medical records system was a major area of need at the outset. Making this commitment allowed hospital workers to reach out to aging patients who were sometimes alone and uncertain about what prescription they should take next.

A heart failure nurse meets with patient and caregiver for intensive bedside counseling. Patient educational programs include an RN case manager, social worker, dietitian, pharmacist, and heart failure program coordinator. Patients also receive an informational letter each week for four weeks to reinforce their discharge education.

"You want to make sure medication reconciliation is done effectively," Jung says. "We have pharmacists do that in the community; we have bedside medication delivery." Sarasota Memorial maintains a partnership with Walgreens that enables the pharmacy to provide bedside pharmaceutical deliveries, and then follows up with patients in their homes. Under the arrangement, Walgreens manages a WellTransitions program with the hospital to provide pharmacy care for heart failure and other contracted health plan patients, both before and after discharge. There is no cost to the patient but the hospital pays a fee to Walgreens for the heart failure patients.

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