How We Improve Care Transitions
“High Risk Initiative”/”HRI” – partnering with 4 local home health agencies to prevent patients identified as at risk of readmission from being readmitted, through the administration of intensive home health care services (RN, SW and other disciplines as needed) above and beyond what is reimburseable beginning within 24 hours of discharge. Close collaboration between the inpatient team and the home health agency continues after discharge for problem solving, including availability of the Clinical Social Work/Care Management Medical Director for emergent management of the patient in the home if the patient’s PCP isn’t available (for example, to give orders to administer lasix to a CHF patient) and for SNF placement from the home in order to prevent an unncessary ED visit or readmission.
For this initiative, 4 local home health agencies (our top four by volume) and area SNFs.
How We Measure Our Efforts
Reduction of 30-day all cause readmission rates for this high risk patient population from 75% for the group prior to enrollment in the HRI program to 25%.
- Address1200 N Elm Street, Greensboro NC 27401-1020
- Primary Contact NameHope Rife, Director, Clinical Social Work
- Primary Contact Emailhope.firstname.lastname@example.org
- Primary Contact Phone336-832-7449