Hospital-to-Home Program Aims to Reduce Readmissions

Medicare patients at high risk for readmission are assigned a care transition coach, often a nurse, who helps them with medication, follow-up appointments, and problem solving.

2 comments on "Hospital-to-Home Program Aims to Reduce Readmissions"
Miguel Ortiz (6/20/2012 at 8:44 PM)

In Ecuador, South America, 25 years ago, we had a coverage-extension pilot program with participation of physicians and nurses training community leaders to work at home with new mothers and their babies right after discharge plus family training. Any problem was immediately referred to the health team. The results were noticed immediately, with increased activity in the outpatient clinics and remarkable reduction of emergency room visits. The impact on breast feeding length was beyond initial expectations. The program, financed in part by UNICEF, was so successful that scholars from around the world visited the city of Guayaquil to see the program in action. The concept works.
Kristin Baird, RN, BSN, MHA (6/19/2012 at 11:55 AM)

Alexandra, thanks for a great article. This is such an important topic on many levels. There are important clinical implications as well as patient experience implications that determine outcomes, loyalty and reputation. I'm glad to see more attention being focused on the transition of care. It's no longer a nice thing to do. It's absolutely necessary that hospitals do post-discharge follow up.


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