by Laura Davie
Reducing preventable readmissions is something my colleagues and industry peers care about — so much so that we worked diligently to secure two federal grants to support this important initiative.
As a project director for the University of New Hampshire Institute for Health Policy and Practice, I have been working with community partners on behalf of the New Hampshire Bureau of Elderly and Adult Services (BEAS) to develop and implement a patient-centric hospital discharge planning model. We’ve put together a state workgroup that includes three hospitals, three ServiceLink Aging and Disability Resource Centers, and several community and case-management agencies that cover three counties.
Our vision is to create a coordinated, patient-centric long-term care system that supports individuals with helpful resources as they transition back into the community and, ideally, to prevent a return visit to the hospital.
We’re hoping to set an example for New Hampshire by taking the time to find out what is right for communities across the state and how social/community providers and medical providers can leverage resources and bridge gaps in care to better serve patients.
Why It Matters.
Our goal is to empower individuals to make informed choices and to streamline access to long-term support including a wide range of in-home, community-based and institutional services and programs.
The ServiceLink Resource Center infrastructure provides an important existing vehicle to drive change and improve quality in communities across New Hampshire. The centers are a trusted place where people can turn for information on the full range of long-term support options.
How ReferralCentral® Helps.
While the grants are partly being used to add appropriate staff, we understand that scalability, powered by technology, is crucial if we are to build out our plan.
The Monadnock ServiceLink Resource Center is a beneficiary of a key technology investment, implementing the Curaspan ReferralCentral referral-management application that gives staff a snapshot of post-acute-care facilities, including home-health agencies, in the area. The software also allows staff to communicate with patients’ primary care providers.
Northeast Rehabilitation Hospital Network is part of a Curaspan-powered network, and we’ve met with its staff to learn best practices. The ServiceLink staff can find answers quickly if there’s a need for a referral.
Who ServiceLink Helps.
ServiceLink Aging and Disability Resource Centers are supported by a strong technology-based infrastructure and a team-based approach for operations management. Trained professionals from various disciplines provide education, information, assessment, customized referrals and connections to both private-pay and publicly supported care options.
The centers are a single point of entry for all long-term care. They serve older adults, younger adults with disabilities and chronic conditions, family caregivers and people planning for future long-term support needs. In addition, the centers are a resource for health and long-term support professionals who provide services to the elderly and to people with disabilities.
How the Project Works.
Our project uses two models. One is called Better Outcome for Older Adults through Safe Transitions (BOOST) and the other is Care Transitions Intervention (CTI), which was developed by Dr. Eric Coleman, MD, MPH, at the University of Colorado Denver. These models complement the referral-management technology.
ServiceLink Care Transitions Specialists provide follow-up support intended to prevent a readmission. For example, in the BOOST model the ServiceLink staff follow up post-discharge with those who are in high need of social supports. A patient who has complex medications would be followed by the pharmacist. Other criteria have been established for more complex medical needs.
Under the CTI model, transition coaches are trained to help the individual identify goals and problems. The care transitions specialist in both models works in the hospital and follows patients as they transition back into the community. They do not provide direct medical care (e.g. no blood pressure monitoring).
The project began in 2009 when New Hampshire received an Administration on Aging (AoA) and Disability Resource Center enhancement award. In late 2010, the state received an additional ADRC grant under the Evidence Based Care Transitions initiative. While it’s too early to see results, we’re confident these efforts are bridging patients’ understanding and access to community-based programs for better transitions from the hospital to home and reducing preventable readmissions.
Laura Davie is the project director for the University of New Hampshire Institute for Health Policy and Practice.
Related Links:
> Six Ways to Use Communication for Good Patient Transitions
> Better Communication Leads to Better Care
> Effective Outpatient Discharges Can Prevent Inpatient Admissions
> Curaspan Hospital Customers Cut Readmission Rate to Below National Average and Saved Almost $260 Million in 2010
