Hospital patient (Getty Image)
Winston-Salem, NC-- A recent study spotlighted hospitals rate of readmissions of patients, especially elderly ones. The study looked at facilities across the country and in the Triad.
Triad hospitals have already started to address the readmission issue with what they hope is a solution based program, in conjunction wit other agencies in the community.
The collaboration brings together several Triad hospitals, local health and social service providers. In addition, the Centers for Medicare & Medicaid Services (CMS) is part of the collaboration as one of 17 additional sites across the nation to participate in the Community-based Care Transitions Program (CCTP).
The Triad consortium is the first in North Carolina to receive CMS funding for a hospital to home transition program.
The goal of the two year program is to help Medicare fee-for-service & Medicaid eligible patients fully recover from serious illnesses after being discharged from a hospital. Also, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.
The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period.
Who's Who in the consortium: Northwest Triad Care Transitions Program (NTCTP), includes Wake Forest Baptist Medical Center, Forsyth Medical Center, Kernersville Medical Center, Northern Hospital of Surry, Hugh Chatham Memorial Hospital, Lexington Medical Center, Thomasville Medical Center, Medical Park Hospital, as well as a large group of community-based health care providers: Northwest Community Care Network, Piedmont Triad Regional Council Area Agency on Aging, Forsyth County Senior Services, Davidson County Senior Services, Surry County Senior Services and Winston-Salem Right at Home.
The program, which can be extended annually for the remaining 3 years if performance goals are met, is designed for Medicare recipients in Forsyth, Davidson and Surry counties who are admitted to a participating hospital with heart failure, heart attack or pneumonia.
Another goal of the program is to have everyone involved in a patient's care talking to each other rather than operating in silos, said Ronald Gaskins, associate director of the Northwest Community Care Network, which will be acting as the lead community-based organization for the program.
"This is a vulnerable group of patients due to their age and high-risk medical conditions," said Gaskins. "We are trying to bridge the transition from hospital to home so these people have what they need to get well. Communication among the various care and service providers is critical to the ongoing health and well being of the patients and their ability to remain independent in the community," Gaskins said. "Simple things, such as filling prescriptions and getting to follow-up doctor appointments, can be daunting if they live alone or don't have a strong social support network to help out."
Using a model designed at Forsyth Medical Center called the Hospital to Home Program, each participating patient will be assigned a social worker who gathers initial information in the hospital and coordinates their care during the first days and weeks after discharge, when there is the greatest danger of relapse and subsequent readmission to the hospital for the same condition.
To see the Kaiser Health study click here.
Wake Forest Baptist Medical Center