Date Submitted: January 2016
Story Submitted by: Karen Preston, RN, BSN, CCM, Director of Case Management, Duke Raleigh Hospital & Director of DUHS Resource Center
Organization: Duke Raleigh Hospital
Location: Raleigh, NC
Care Transitions Across the Continuum
Description of Population Served:
Discharged patients with high risk needs that require Home Health services.
The Duke Raleigh Hospital Case Management Team meets with top Home Health agencies to review readmissions from the previous month, answer questions of when start of care began, any ED visits or contact with MD, and shares new resources and opportunities for improvement from what we learned from our review of patient services.
Improve communication and accountability with our post-acute providers that provide home care services.
Meeting monthly with home care representatives to review the previous month’s readmissions. Questions asked about readmitted home care patients: What disciplines were involved, what was the initial start of care date, any referrals made of other disciplines, any reporting to the MD of concerns, any ED visits in between readmissions, any refusal of care for any of the disciplines?
Building relationships with our high volume home care providers, assisting in proactivity with SW referrals, palliative care, etc.
It takes a village and we must continue to build strong relationships with our home care agencies to provide quality care transitions, increased patient satisfaction, positive patient outcomes and reduction of readmissions.