SETMA's Care Transitions to Reduce Preventable Hospital Readmissions

Published on Nov 11, 2012

The Institute for Healthcare Improvement's Triple Aim is to improve care, improve health and decrease cost. A difficult problem in healthcare is the frequency of 30-day readmission to the hospital. Often the cause for readmission are related to medication problems and to poor care transitions. SETMA has designed a care transition program which combines the forces of a hospital care team with informatics and care coordination to:

1. Provide a hospital plan of care to patients upon admission
2. Complete a Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan at discharge which includes a reconciled medication list, an assessment of risk of re-hospitalization, and follow-up appointments within 2-5 days.
3. A Care Coaching call the day after discharged from SETMA's Department of Care Coordination

SETMA's program has led to a 20% decrease in re-hospitalizations and a 37.4% decrease in cost of care for Medicare beneficiaries.

SETMA’s Care Transitions to Reduce Preventable Hospital Readmissions is built upon work done through SETMA’s innovation but which work is built upon the published works and contact with:

1. IHI -- Institute of Healthcare Improvement - Triple Aim and Moral Test of a Government
2. PCPI -- AMA's Physician Consortium for Performance Improvement - Transition of Care Quality Improvement Data Set
3. NQF -- National Quality Forum - Care Transitions Seminar and hospital readmissions publications
4. NCQA -- National Committee for Quality Assurance - Care Coordination and Patient-Centered Medical Home
5. AAAHC -- Association for Accreditation of Ambulatory Health Care - Care Coordination and Patient-Centered Medical Home
6. PC-PCC -- Patient Centered Primary Care Collaborative
7. PCT-LEAP -- The Primary Care Team Learning from Effective Ambulatory Practices (PCT-LEAP) Robert Wood Johnson Foundation

The following is a description of the RWJF video contest

10.24.12

Hi, Dr. Holly:

I’ve seen information about your efforts to better coordinate patient care through hospital care summaries and treatment plans and coaching calls—congratulations, what amazing work. I thought it would make a perfect entry for the Robert Wood Johnson Foundation’s Transitions to Better Care video contest. We’re looking for stories of innovative ways hospitals, primary care practices, post-acute care facilities and others are 1) improving care transitions and care coordination and 2) reducing avoidable hospital readmissions. A simple recording device, like those found on smart phones, is all you need to enter.

By participating, you and your colleagues can win:

1. A trip to Washington, DC to participate in taping of a special webisode to discuss your intervention with Nancy Snyderman, MD, chief medical correspondent for NBC News and Risa Lavizzo-Mourey, MD, President and CEO of the Robert Wood Johnson Foundation;
2. A professionally-produced video describing your innovation; and
3. Special recognition from the Robert Wood Johnson Foundation.

I’ve included more information below—we’d love to have your participation. You can also visit the full contest rules at www.rwjf.org/goto/yourcare.

Transitions to Better Care Video Contest

The Robert Wood Johnson Foundation is sponsoring a video contest to highlight what specific hospitals, primary care practices and post-acute care facilities are doing to improve care transitions and reduce avoidable hospital readmissions. Nurses, care coordinators, doctors, patients and others are encouraged to share examples of what people are doing to effectively coordinate care plans.

The Transitions to Better Care video contest is part of RWJF’s Care About Your Care effort. Contest organizers seek examples of innovative approaches to improve the way patients and their care teams communicate, especially when a patient is transitioning from the hospital to home or interim or long-term nursing care.

A simple recorder like those found on most smart phones is all that contest entrants need to prepare a short video for the contest.

Contest winners will receive a trip to Washington, DC to participate in taping of a special webisode on effective care transitions and discuss their interventions with Nancy Snyderman, MD, chief medical correspondent for NBC News and Risa Lavizzo-Mourey, MD, President and CEO of the Robert Wood Johnson Foundation. Winners will also receive special recognition from the Robert Wood Johnson Foundation, a professionally produced video describing their innovation, and the opportunity to discuss their methods with patients and health care providers nationwide.