The nuances of creating a care transitions program based on predicted readmission risk

Those who plan to start a care transitions or care coordination program need to be aware of the challenges that go into doing this successfully. In developing a Care Transitions Program; they should know how to utilize the performance improvement processes and analytics, and also know how to put all these together for optimal benefit. They should know what needs to be measured and how to demonstrate outcomes.
Without proper knowledge of these vital aspects, a care transition or care coordinator program founder could be up against many obstacles. The dynamics of these programs and the ways of handling them in order to leverage technology for better outcomes will be the objective of a webinar that is being organized by MentorHealth, a leading provider of professional trainings for the healthcare industry.
A thorough and well-structured session on a care transitions program
At this session, the speaker, Sherrill Rhodes, a senior nurse who serves as the Accreditation Specialist at the Malcolm Baldrige Awardee Baptist Hospital in Pensacola and brings over 30 years of nursing experience and 14 years in Quality Leadership, will explain these issues.
To understand the nitty-gritty of managing a care transition or care coordination program successfully without hiccups; please register for this session
Based on extensive research
This webinar familiarizes those starting up a care transitions or care coordination program with the challenges this profession provides. It will teach them what needs to be measured to ensure desired outcomes.
The content of the learning for this webinar will be based the findings of a comprehensive transition program a 402-bed regional medical system has developed to identify and guide patients from acute care through comprehensive discharge planning and community care. This program identified key areas using transition nurses to proactively manage patients with a high risk of readmission, by which hospital readmissions were reduced.
The modified LACE (Length of stay, Acute admission, Co-morbidities and ER visits) tool the transition program used to identify patients at risk for discharge delays and/or readmissions and analytics to evaluate target populations was a major reason for its success. Various parameters went into these analytics, the end result of which was the attainment of goals such as improved patient experience, promotion of health and wellness in the community and reduction in readmissions.
Extensive use of analytics
At this webinar, Sherrill will explain the findings of this research, which used analytics to help the researchers correlate the patient risk of readmission with the actual observed readmission rate, the total cost of readmission encounters, and the clinical drivers of readmissions.
Analytics were also used for providing a financial model that calculates the overall impact of readmission rate reductions on reimbursement, cost, and value based purchasing payments. The program targeted populations that required a 30-day readmission for any cause and followed specific clinical populations of AMI, Heart Failure, Pneumonia, Hip/Knee Replacement, Stroke, COPD, and Sepsis.
Assigning LACE scores
Using analytics, the researchers assigned a LACE score of 13-16 to identify intense resources or a readmission is likely to occur. They also took community resources such as medication assistance, transportation vouchers, self-monitoring equipment and home care navigators into consideration for assisting in maintaining home placement for these patients. Unfunded patients get supplies of medications, equipment, etc. through community resources. These were aligned to the grading system, by which patients with scores above 8 receive a 3 -7 day follow-up, and patients with a score above 12 receive a full 30 days of follow-up.
The main goals of this research was to bring about improvement in the patient experience, promoting health and wellness in the community and reducing readmissions. That collaboration between acute care and the community resources has proven beneficial to all involved has been established beyond doubt. As a follow-up to these objectives, the researchers are involved in understanding and monitoring their readmission trends.
This webinar will discuss this program in greater length. It will be of value to Quality Directors, Nurse Leaders, Senior Data Analysis, Case Managers, Community Navigators, Care Coordinators, Physicians, and Physician Office Staff.