Care Transitions/Readmissions

The Health Council and its members are working toward specific common goals of reducing readmissions and improving not only the care that a patient receives when he or she is at the hospital, but also the care that is provided when the patient transitions back into the community.

Some of the most notable Council-led achievements and efforts include:

• Southwest Ohio Care Transitions Collaborative – Care Transitions, a health coaching and intervention program launching in five hospitals in 2012 and funded via a contract with CMS, is designed to help frail seniors who have been discharged from the hospital avoid future preventable hospital admissions.
• Accountable Care Transformation Leadership Team– Participating hospitals have committed to reduce heart failure all-cause heart failure readmission rates for the 18 years and older population.
• EMR Discharge Summary – The goal is uniform adoption by hospitals of a consistent electronic medical record discharge summary to improve patient care transitions and outcomes.
• Nursing Facility to Hospital Transfer – Long-term care and emergency department representatives have collaborated to achieve time and resource savings by improving patient transfer communication.

In addition, the Council is exploring the feasibility of a community-wide patient navigator program modeled after the success of one member hospital in the community to reduce readmissions. Work is also under way to standardize medication labeling community-wide to facilitate patient compliance and understanding.

Regional Health Care Transformation Efforts

The Council also coordinates members’ participation in regional health care transformation efforts, such as the federal Beacon Community Program and Cincinnati Aligning Forces for Quality that aim to improve care transitions and reduce readmissions.