Hospital Re-Admission Reduction Services

Our hospital re-admission reduction services are designed to lower re-admission rates by providing intensive care coordination and case management services intended to identify and overcome any barriers that may prevent our clients from receiving appropriate out-patient clinical services at the appropriate time. This includes insuring our clients have access to the necessary socioeconomic resources they need to become and stay well and follow through on their prescribed clinical treatment plan.

Primary Program Goals

The success of our hospital discharge care management programs are based upon a singular focus on achieving the following goals:

Relationship Building

create and maintain positive working relationships with our clients built upon the ideal of mutual trust and respect

Patient Centered Care Plan

work with the client, the client’s family and caregivers, and the client’s providers in the development of a patient centered care plan

Primary Care

ensure the client obtains a post-discharge follow-up visit with a primary care physician within 3-7 days of discharge

Specialty Care

ensure the client obtains all necessary specialty care services in an appropriate timeframe

Medications Reconciliation

ensure the client obtains a reconciliation of their medications within 3-7 days of discharge

Home Health Care

ensure the client receives any necessary home health services in an appropriate timeframe

Self-Management and Health Literacy Education

ensure the client obtains the education and skills necessary to become effective self-managers of their primary diagnosis and any related co-morbidities

Socioeconomic Needs

ensure the client gains access to the services and resources they need to become and stay healthy

Points of Engagement

Initial Engagement

the initial engagement is done in-person at the provider’s office and focuses on relationship building and completing a risk/needs assessment.

Supportive Engagements

supportive engagements are done at pre-prescribed times and allow us to engage the client in a comprehensive and holistic way. We engage high risk clients at least once a month with a focus on relationship building, reassessing and making appropriate modifications to the care plan, and providing self-management education and support. Whenever possible these supportive engagements will take place in person at the provider’s office to assist in the care planning process.

Dynamic Engagements

dynamic engagements happen as needed to provide coordination of the clinical treatment plan and socioeconomic case management.

Program Outcomes

of the clients in our Medicaid hospital discharge program obtained a primary care follow-up visit within 14 days of discharge

of all specialty visits that were prescribed as a part of the hospital discharge treatment plan were obtained

of our clients obtain a medication reconciliation with either a primary care provider or pharmacist within 7 days post discharge

we have reduced the overall 30 day hospital re-admission rate of our partners by 19.1%

We’ve reduced the 30 day re-admission rate of our clients with congestive heart failure by 15.9%

We’ve reduced the 30 day re-admission rate of our clients with chronic obstructive pulmonary disease by 25.5%

We’ve reduced the 30 day re-admission rate of our clients with acute myocardial infarction by 26.9%

For more information about our care management programs and how we can help you achieve your organizational goals.

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