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Community Care

Reduce Re-admissions by Improving Hospital-to-Home Transitions

Jeff Doleweerd
April 6, 2016

In the US Medicare population, up to 76 percent of rehospitalizations occurring within 30 days of discharge are avoidable. Rehospitalizations represent a significant source of waste and harm in the healthcare system.

Research shows that enhanced care and support during transitions is an effective method to reduce rehospitalizations. This is because newly discharged patients are vulnerable to adverse events while they wait to learn about the next steps in their care.

The Institute for Healthcare Improvement (IHI) has published a helpful How-to Guide for improving transitions from the hospital to community settings to reduce avoidable rehospitalizations. One of their key recommendations involves scheduling the next steps in care, before the patient leaves the hospital.

“Key Change 3B – Prior to discharge, schedule timely follow-up care and initiate clinical and social services.”  – Institute for Healthcare Improvement

Clinicians can ensure that, before the patient is discharged, patients have the help they need by booking directly into appointments with trusted services in the community. This reduces avoidable readmissions, diminishes potential harm and alleviates caregiver and patient stress.

Booking the next appointment before discharge may seem ambitious. However, when hospitals work together with their community health service provider agencies, the discharge process can actually be simplified.

“Teams have succeeded in successfully scheduling appointments by partnering with providers to create a simplified process, and by getting patient input regarding the best times for them to arrange transportation” – Institute for Healthcare Improvement

At Caredove, we provide the online platform that enables health care organizations to partner together to create a simplified transition process with scheduled appointments before hospital discharge. The result is that hospitals can reduce readmissions, discharge planners can better coordinate care, and patients know they will get the care that they need.

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