Care Transitions, a Key to Reducing Hospital Readmissions

Care transitions is at the core of what Kissito Post Acute is all about, as it is one of the four centers of excellence of the Collaborative Patient Care Model ^TM.  Care transitions, is the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. It is rapidly gaining recognition  nationally in the light of recent healthcare reform discussions. Researchers have found that 20 percent of Medicare beneficiaries return to a hospital within 30 days of discharge, increasing the cost of care for people in their later years.  Dr. Eric Coleman, creator of the Care Transitions Program℠, found that a transition intervention care program reduces the incidence of rehospitalization for up to 180 days.

In 2007, the California HealthCare Foundation (CHCF) initiated a year-long, $650,000 project to bring the Coleman Care Transitions Initiative (CTI) to ten centers to improve transition care. The use of CTI resulted in lower readmission rates and researchers estimated that for every 350 patients receiving an intervention, costs were cut by nearly $300,000. With 800 patients reached in the CHCF effort, the intervention nearly paid for itself.

Kissito Post Acute staff are being trained on the Coleman Care Transitions Program℠, which is a four-week program encouraging patients to take a more active role in their healthcare. Patients receive tools and skills to assist in their self-care and are reinforced by a transition coach, who follows patients across settings for the first four weeks after leaving the hospital. The transition coach will emphasize:

• Medication self-management
• A patient-centered health record to guide patients through the care process
• Follow-ups by specialists and primary care providers
• “Red flag” awareness of indicators of worsening conditions and “next steps” for patients.

The patient-centric focus of the program includes measures for families and caregivers to ensure their comfort with the care regimen and the self-activation of the patient. The care delivery tool kit also includes a personal health record and medication discrepancy tool. After the intervention, patients are empowered and more capable and willing to manage their daily healthcare.