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Hospital-to-Home Program Aims to Reduce Readmissions

Alexandra Wilson Pecci, for HealthLeaders Media, June 19, 2012

"It's going really well," Riehle says of Fairfield's program. "Our coach did 10 home visits the first week she was here."

Although Fairfield Hospital is only a few weeks into its program, Riehle says that the pilot program that their grant was based on decreased the readmission rate for the target population to 7.5%, which is about a third of the national rate.

Also, she says nurses have already learned a lot about the challenges patients face at home.

"I think the thing that surprises them the most is how confused patients really are about their medications," Riehle says.

The focus on readmissions has also broadened nurses' view of healthcare.

"In acute care, we always lived in our own little world….and we really have to think about managing that patient across the whole continuum," Riehle says, "so they don't just bounce right back to us."

That broadened view of healthcare puts the patient in a larger context than just their hospital stay. Riehle says it also requires partnerships between a wide range of stakeholders in the larger community.

"I think we're going to have to really think about ‘how do we manage those relationships?" Riehle says.

Or, put a different way: "How do we do a good hand-off?" 


Alexandra Wilson Pecci is a managing editor for HealthLeaders Media.

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2 comments on "Hospital-to-Home Program Aims to Reduce Readmissions"


Miguel Ortiz (6/20/2012 at 8:44 PM)
In Ecuador, South America, 25 years ago, we had a coverage-extension pilot program with participation of physicians and nurses training community leaders to work at home with new mothers and their babies right after discharge plus family training. Any problem was immediately referred to the health team. The results were noticed immediately, with increased activity in the outpatient clinics and remarkable reduction of emergency room visits. The impact on breast feeding length was beyond initial expectations. The program, financed in part by UNICEF, was so successful that scholars from around the world visited the city of Guayaquil to see the program in action. The concept works.

Kristin Baird, RN, BSN, MHA (6/19/2012 at 11:55 AM)
Alexandra, thanks for a great article. This is such an important topic on many levels. There are important clinical implications as well as patient experience implications that determine outcomes, loyalty and reputation. I'm glad to see more attention being focused on the transition of care. It's no longer a nice thing to do. It's absolutely necessary that hospitals do post-discharge follow up.