How can you reduce hospital readmissions through care coordination and transitional care management?

Pay attention, appreciate and train and trust your Environmental Services Department. That is the team that is truly responsible for being the first line of defense and the prevention of Hospital Acquired Infections

To decrease a readmission we identified up to THREE pre-admission contributing factors that could be modified with patient education and monitored by homehealth and pcp communication day 1-3 and 7-14 post discharge. When an additional family member was involved in care and educated about the goals, readmission was less likely to occur. A more focused individualized approach with limited participants who kept each other informed in real time, also resulted in high patient satisfaction.

Care coordination shouldn’t be just a list of appointments and a sheet of instructions given to the patient. Care coordination is all about educating the patient and their close ones about the reasons they need to do different tasks: appointments, therapy, diet, exercise, etc. The key to that education is number of “touches”(communications) and the understanding by the patient or family. The understanding depends on sensorium, literacy, and information retention.

This is a difficult question to answer, as it assumes that readmissions are caused by lack of care coordination, which may only be partially true, but might not necessarily be the main reason for readmissions. Also other assumptions can be misleading - for example the claim that duplication of services leads to readmissions, therefore prevention of duplication will reduce the problem. I suggest to whoever is trying to address this challenge is to review the evidence first. Perhaps improved hospital care can help? Rewritten protocols for discharge in the first place? Are we rushing patients out of hospitals when they are not fully ready to be discharged? Is new infrastructure needed?

Hello guys In my opinion the best way to reduce readmission of surgically treated patients, is scientific preoperative management, reducing duration of hospitalization , management of aseptic operation field and minimize the duration of antibiotic therapy .

Reducing hospital readmissions through care coordination and transitional care management involves pre-discharge planning, medication management, patient education, coordination with post-acute care providers, follow-up appointments, telehealth services, transition liaisons, community resources, and comprehensive discharge instructions. Transitional care management (TCM) encompasses services designed to assist patients during critical post-hospitalization periods, minimizing complications and readmissions.

By ensuring that both the patients and caregivers are trained and well supported by the healthcare team to handle the discharged patients will significantly reduce hospital readmissions. Employing empathy and recognizing caregiver efforts increases confidence and increases positive patient outcomes

Implement a transitional care management program that provides support to patients as they move from the hospital back to their home or another healthcare setting.

Reducing hospital readmissions through care coordination and transitional care management (TCM) involves several strategies and interventions include: 1. Transition Care Coordinator (TCC) Model: This model involves trained nurses who coordinate with inpatient clinical teams. 2. Enhanced Discharge Planning, Care Coordination, and Transitional Care Programs. 3. Interactive Contacts, Face-to-Face Visits, and Non-Face-to-Face Services: TCM services consist of three components. 4. Quality Improvement Methods: Implementing quality improvement methods in healthcare systems can help reduce readmissions by identifying and addressing areas for improvement in care transitions and patient management.

Transitional care management is managed either through protocol based public health services or care coordination in the privately funded services. It needs well staffed and capabable physicians in the lower down-referral system to ensure continued quality care is provided at all times. The challenge to all of us is referring patient to someone you don't know their skill set and most of the time with limited resources and/or facilities to manage the patient. A skills transfer is very important in this area of care and continued engagements between this levels of care.

Digital health integration amplifies the efficiency of healthcare synchronization. Electronic health records, telemedicine, and wearable technologies play pivotal roles in connecting care levels. These innovations facilitate real-time data sharing, enabling healthcare providers to make informed decisions promptly. Patients benefit from remote monitoring and personalized interventions, fostering a proactive approach to healthcare. The integration of digital health not only enhances communication but also empowers individuals to actively participate in managing their well-being, marking a transformative era in healthcare delivery.

SNFs have a unique ability to help reduce rehospitalization for residents who have been under their care. There needs to be a few things in place in order for them to make an impact. Residents/families need to be educated on signs/symptoms of their health problem. They should be instructed to communicate these concerns timely to their home health provider or community physician to enable early assessment and treatment of the issue. Facilities also must educate community PCPs and HHC companies on the care that can or provided in the facility. The resident may likely be able to return to the SNF for care, rather than being admitted to the hospital. Regular follow-up calls after discharge can allow SNFs to provide guidance as well.

Implementing care coordination and transitional care management involves adopting best practices and leveraging various tools and resources. Utilize standardized protocols and checklists to identify high-risk patients, assess their needs, provide instructions, and monitor progress. Electronic health records (EHRs) and health information exchange (HIE) systems help bridge gaps in care, reduce errors, and enhance communication. Embrace telehealth and remote monitoring technologies for ongoing support in diverse settings. Streamline workflows with care management software, automate reminders, and generate reports.

Implementing care coordination and transitional care management involves a comprehensive and collaborative approach that integrates strategies across healthcare settings. Assess Organisational Readiness - Evaluate the organisation's current infrastructure, resources, and culture to determine readiness for care coordination and transitional care management. Establish Leadership and Governance - Appoint a dedicated leadership team responsible for overseeing and driving the implementation process. Define Care Coordination and Transitional Care Goals - Clearly define the goals and objectives of care coordination and transitional care management based on the needs of the patient population and organisational priorities.

One of the main factors is being able to convey clearly the service offering to the clinicians that will use it. They will be the ones assessing if the patient is the right fit for the service. So no matter what your protocol is and how good you are make sure to create that connection. Deploy a liaison between the service and the hospital. More effectively in the ER to intercept patients that can benefit from the service and avoid admissions.

Care coordination and transitional care management lead to tangible benefits, such as reducing hospital readmissions. For instance, a recent implementation of coordinated home-based care for post-surgery patients resulted in a 20% decrease in readmission rates and heightened patient satisfaction.

Some benefits of care coordination and transitional care management are reduced hospital readmissions - Improved coordination ensures that patients receive appropriate follow-up care, reducing the likelihood of hospital readmissions. Another benefit is enhanced patient outcomes - coordinated care plans and effective transitions contribute to better health outcomes by addressing patients' medical, social, and behavioral needs.

The benefits are the advancement Triple Aim—Better patient outcomes and satisfaction along with improving population health. Better efficiency during an episode builds a framework that the patient can continue to expect and contribute with future episodes. This has payback for patients and payers.

A implantação de coordenação do cuidado e gestão transitória de pacientes hospitalizados, apresenta resultados de desfecho clínico muito mais relevantes quando comparada a pacientes com cuidado hospitalar fragmentado e com ausência de gestão transitória. A coordenação do cuidado em internação hospitalar pode ser implantada por meio de protocolos clínicos, integração dos dados e informações de registros de evolução do paciente, tanto de equipe de enfermagem quanto de equipe médica, reuniões periódicas e multidisciplinares de discussão de evolução do caso clínico. Em relação aos cuidados transitórios, pode-se implementar protocolos clínicos de desospitalização, categorizados por risco.

O maior benefício que se pode ter é enraizar os princípios Lean Healthcare, que por consequência geraria lucro e cortes de custos desnecessários, pois tempo seria economizado, com isso filas seriam abolidas e o usuário dificilmente seria encaminhado para um cuidado complexo, que por si, seria um grande custo. Pois os problemas seriam solucionados antes de chegar em procedimentos de alto custo.

Care coordinators are working intimately with patients and families who’ve been through a life altering event. This an emotionally grueling job. There is often high turnover and burnout. Machine learning may aide the team in the future, which is hopeful. In the mean time, increased funding & resources to these teams is severely needed.

And..... that is the essence of good Primary Healthcare from your trusted Gp. This work deserves appropriate funding. It is our Gps who can truly integrate care and bend the cost curve while delivering better outcomes for the person.

A challenge for clinicians is to keep the ability to take a step back and look at the bigger picture of the patient journey. We have, understandably, a tendency to focus on our own tasks, budgets and responsibilities. This is important to manage workload/flow and meet quality standards. On the other hand, when we support colleagues in other parts of the healthcare system, eg through timely, comprehensive and respectful communication and clinical handover, we facilitate safe continuity of care for our patients beyond the boundaries of our consulting rooms, clinics and hospitals. Moreover, this will result in less representations and complications and improve patient and clinician satisfaction.

When a Dr says their patient is fit for discharge it is from a medical perspective only. Comprehensive case management and discharge planning is often required to facilitate a safe discharge home, this may involve organising pressure injury prevention equipment, organising home care/nursing and allied health referrals. Sometimes a home visit with Allued Health is useful before discharge to enable acquisition if equipment. If these steps are taken, yes tge discharge may take a little longer but it can prevent readmission to hospital. Thus will provide safe and seamless transfer if care and keep readmission rates and incidents down.

Improving communication and connections with primary health care services and local communities are key aspects of effective care coordination. These aspects can be too easily overlooked in our very fragmented health care system where a specialisation focus sometimes loses sight of the individual in case management.

The following issues still pose challenges to the questions raised and makes it difficult to have a clear approach that physicians and health providers can apply: 1. Different health funding models with their different processes and expectations to health providers. 2. Non-intergretad electronic health records where they exist, limiting access to full patient information and affecting care. 3. Limited skilled human resources especially at lower levels of care, which compromises quality of health care at this facilities. Leads to the higher levels of care holding patients for longer which increased costs and expose patients to unnecessary infections in hospital.

Don't shy away from using the resources available to you. Many of us work with other learners whether medical students, residents, fellows, NPs, PAs, RTs, etc. I always ask the entire team, one by one, if they have any concerns about my patient being discharged.

The most frequent reason behind hospital readmissions is: Hospital Acquired Infections. Here are a few measures that can be taken to avoid these: 1. The correct and frequent hand hygiene measures by all staff and patients. 2. keeping the healthcare environment and equipment clean. 3. Complying with standard sterile techniques when performing surgery 4. Caring for wounds or inserting and caring for medical devices such as intravenous cannulas and urinary catheters.

As with any complex problem, one should ask what work is necessary to get an optimal result. Then one asks "who in the larger community could do each of these tasks?". Then ask "how can we best use these resources to remove excess burdens on those who are over-burdened while respecting the potential of all people who could help?". Many caring people in our communities would help if only they knew they could.

There are various models of community care, including transitional care, that aim to keep the patient at home and away from the hospital and prevent hospital admissions and readmissions.They mainly focus on the frail & elderly population and are based on previously discussed and agreed long term care plans between primary care MDTs, selected specialists, patients and families.The problems with all these models are sustainability and long term effectiveness, both requiring a cultural change.This kind of cultural change can only be achieved through the leadership of experienced physicians, who will be keen to take responsibility for remote patient care and, of course, be appropriately supported and empowered to do so for as long as necessary.