RightTransitionsSM

RIGHT AT HOME’S INITIATIVE TO REDUCE HOSPITAL

READMISSIONS

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CARE TRANSITIONS DEFINED

The movement patients make between health care practitioners and settings

Examples of problems: Patient confusion Medication errors Poor follow up with PCP

HOSPITALS UNDER PRESSURE TO REDUCE READMISSIONS 1 in 5 are preventable Most are preventable

76% Readmits cost $7,200 each

~$25 billion/year

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WHY A TRANSITIONAL CARE PROGRAM? Change in environment

Penalties Transitional programs work!

Save the hospital moneyIncrease the quality of care

PROGRAM OVERVIEW

Service Offerings:Identify red flagsCoordinate careCommunicate with other care providersMeal preparation, medication reminders and

transportation

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FORSYTH H2H PROGRAM

Program Outcomes*65% reduction in readmissions99% patient satisfactionCost per readmit → $7,661Hospital savings → $1.1 million

Right at Home OutcomesAverage hours of RAH services → 23.7

*As of November 2010

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FORSYTH H2H PROGRAM

Program Design: Patient eligibility determined (based on risk factors) Hospital Navigator explains program to eligible patients Hospital Navigator communicates plan of care to RAH

(e.g. number of hours, patient details, transportation needs, red flags)

Service starts; RAH assigns staff Weekly communication on each patient between

Navigator and RAHRevise plan of care as needed

Service ends

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FORSYTH PROGRAM UTILIZATION

Meals/Shopping – 35% Transportation – 34% Housekeeping – 49% Medication Reminder – 8% Other – 25%

Meals/Shopping

Transportation

Housekeeping

Medication Reminder

Other

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OTHER Right At Home TRANSITIONAL CARE PROGRAMS:

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NEXT STEPS

Follow up with additional information

Discuss date for next meeting/call

RIGHT AT HOME FOX VALLEY AND CHICAGO SW SUBURBS

KATHY WETTERS630-780-9766

KWETTERS@RIGHTATHOMECARE.US

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