Keys to Managing Transitions of Care

Joe Cantlupe, for HealthLeaders Media , May 23, 2013

The arrangement with Walgreens was motivated by the need for care for patients after they leave the hospital. "If you don't have an onsite retail pharmacy, it makes it a lot harder for patients to get their medications," Jung says. Sarasota Memorial physicians must ensure they are complying with the medication reconciliation programs "or they can't discharge a patient."

Coordinating care for elderly patients is especially important, and that's why Sarasota is forging relationships with nursing homes, too. "That's where one-third of our readmissions come from," Jung says. Over the last two years, Sarasota has improved its bonds with local nursing homes. There are some aspects of patient care, such as improving diet, that can only be successful if different health facilities agree on the plan to achieve it. With some nursing homes, "we've talked openly about the fact they've got salt and pepper shakers on the table. A few of the nursing homes follow through and give their patients salt-restricted diets," he says.

Those conversations with nursing homes, as Jung sees it, are "baby steps toward clinical integration."

Case management of patients after they leave the hospital is also becoming more important, he adds. The hospital has begun a pilot "transition case manager program" to help monitor patients, which includes home visits. Many of Sarasota Memorial's patients are discharged to an empty home, or to one with an elderly care giver. "They've got baking soda, fried food, and soup with a lot of sodium. And in the refrigerator there's a six-pack or two of beer. If you are going to knock down the readmissions, somebody needs to do a home visit and see what's going on at the home," Jung says.

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