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Managing the Continuum

Marianne Aiello, for HealthLeaders Media, October 13, 2011
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In addition to verbally explaining discharge instructions, Saint Luke’s care coordinators also put together a red discharge binder for each patient. The binder contains a patient handbook, personalized patient education information, specific discharge instructions, and a follow-up appointment card for a patient, if needed.

Saint Luke’s also sends a discharge summary to each patient’s primary care physician. If a patient does not have a PCP, the care coordinator will work with the patient and his or her family to find one. Thaker has found that keeping PCPs informed has benefits beyond improving the patient’s care.

“Doing that really creates the perfect relationship with the PCP and that’s why they prefer to send the patient to your hospital, because they know how well you’re coordinating their care,” she says. “We make 98% of our patients who need an appointment schedule one before they leave the hospital.”

Since Saint Luke’s began focusing on improving readmission rates, its potential avoidable days have decreased from 11 days per month to three days per month. The hospital also decreased insurance denial days, including four months in a row where not a single day was denied.

“Every denial is going to cost you money,” Thaker says. “It also takes energy and multiple resources to write the denial letter, fight the denial process, and get it turned around, so we’re saving money and valuable time.”

Saving time

In addition to saving money by reducing readmissions and potential avoidable days, both Mayo Clinic and
Saint Luke’s found that better managing the continuum of care saves a
good deal of time and improves the patient experience.

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