- Website URLhttp://www.lenoirmemorial.org
- Phone Number252-522-7000
- Fax Number252-522-7007
How We Improve Care Transitions
Recently began Patient Care Transitions department/program for our hospital to focus on optimal care transitions and reduce readmissions. Director of Nursing is in development phase of program. Three clinical nurse educators are being repurposed to focus on strategies to ensure patients are ready for transitions to home and follow up to reduce readmissions.
Established a new program focused on patient care transitions and readmission reduction; designated nurse educators visiting patients at moderate or high risk for readmission while hospitalized and completing follow-up phone calls post discharge, post MD follow-up visit and prior to 30 days. Concentrated efforts to ensure patients have most cost-effective prescriptions at discharge. Scheduling MD follow-up visits prior to discharge. Identifying high risk patients at multidisciplinary physician/staff huddles daily.
- Lenoir County EMS initially for identifying patients who have frequent readmissions
- Community Care
- Private physician practices
- Hospitalist physicians.
How We Measure Our Efforts
Of present, only reporting readmissions date, no drill down to root cause and gaps/barriers for readmissions.
Established metrics for monitoring readmission reduction, preventable readmissions, follow-up appointments made and kept, health confidence score increases from admission to 30 days post discharge.
- Address100 Airport Rd, Kinston NC 28501
- Mailing AdressPO Box 1678, Kinston NC 28503-1678
- Primary Contact NameElaine Q. Penuel, MSN, RN - Director of Nursing/Patient Care Transitions
- Primary Contact Emailepennel@lenior.org
- Primary Contact Phone252-522-7959