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	James L. Holly, M.D.

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In The News - SETMA’s video submitted to the Robert Wood Johnson Foundation’s Video Contest

SETMA’s video submitted to the Robert Wood Johnson Foundation’s Video Contest

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:

Provide a hospital plan of care to patients upon admission
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.
A Care Coaching call the day after discharged from SETMA's Department of Care Coordination

For The Complete Announcement or More Information- Click Here

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