Being admitted to the hospital is often a necessary experience but being readmitted to the hospital shortly after being discharged is something most patients simply want to avoid. Jamaica Hospital’s newly implemented Care Transitions Program is a momentous effort the facility is taking to provide proactive medical and social interventions to patients who pose a high risk for hospital readmission.
One major component of the new program is Community-Based Care. Two teams were developed to reach patients who typically don’t have repeated in-hospital stays, but are still at risk for hospital readmission because of their health status or other risk factors.
Both teams consist of a nurse practitioner, a care coordinator, and a community care assistant. The teams monitor 30-40 patients each, for up to 29 days, and work closely with the patient’s primary care physician to ensure coordination of health care needs for 30 days post discharge. To best meet the needs of the patient, health care interventions, such as medication reconciliation, referrals to health care services, and management of medical services, are provided in the home and/or the community. After the completion of 30 days, patients may be referred to ongoing services in the community, ongoing monitoring by their primary physician, or to the hospital’s IMPACT program, another aspect of the Care Transitions Program that specifically provides long term, managed care to patients who have repeated in-hospital stays.
“The idea behind our care transitions initiative is to provide interventions in the home to high risk individuals and to reduce the risk of preventable readmissions,” said Dr. Angelo Canedo, Vice President at MediSys Health Network. “We understand that hospital stays are usually unwanted by patients. It’s taxing, both emotionally and physically, for patients, and their loved ones.”
He added, “with Community-Based Care, we are able to provide our patients with preventive measures that will help keep them out of the hospital, improve the quality of care they receive, and provide them with care in the comforts of their own home—all significant benefits.”
Jamaica Hospital’s Care Transitions Program is aimed at cutting 30-day readmissions by at least 20%, which is also aligned with the government’s recent effort to decrease hospital readmissions, and increasing community based/ambulatory care.
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