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Hospital-to-Home Program Aims to Reduce Readmissions
Medicare patients at high risk for readmission are assigned a care transition coach, often a nurse, who helps them with medication, follow-up appointments, and problem solving.
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*MAGNET™, MAGNET RECOGNITION PROGRAM®, and ANCC MAGNET RECOGNITION® are trademarks of the American Nurses Credentialing Center (ANCC). The products and services of HCPro, Inc. and The Greeley Company are neither sponsored nor endorsed by the ANCC. The acronym "MRP" is not a trademark of HCPro or its parent company. HCPro, Inc. is not affiliated in any way with The Joint Commission, which owns the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and Joint Commission trademarks, the Accreditation Council for Graduate Medical Education, which owns the ACGME trademark, or the Accreditation Association for Ambulatory Health Care (AAAHC).
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.
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.