In January 2011, URMC, a healthcare delivery network anchored by the 800-bed Strong Memorial Hospital, started its Safe Transitions program to focus its attention on successfully moving patients out of the hospital to their next site of care, whether it be to a skilled nursing facility, a rehab center, or their own home.
The program's goal is to drive down 30-day readmissions by 15%. "It's a multidisciplinary program focused on areas like medication reconciliation and management and early discharge follow-up," Berliant says.
"Our idea is that for high-risk patients, the minute they are admitted to the hospital, they need intensive attention. We are planning their discharge on that day of admission. We are rounding on them with a pharmacist, a social worker, a case manager from their patient-centered medical home… We are trying to see if micromanaging these patients might result in better outcomes."
Before patients are discharged, nurses and case managers cover a checklist of items with them, such as making sure they can access their medications and that they understand how to take them and what the potential side effects may be. Staff use teach back techniques to confirm that patients fully comprehend their care instructions and also set up a follow-up appointment with a primary care doctor.
After discharge, case managers continue to support patients through telephone consultations in which they address the medical and social barriers that may prevent patients from recovering their health.