Bassett Healthcare Reduces Readmissions with Patient Support

A patient's home environment or lack of support system can have a negative impact on their health and result in preventable hospital readmissions. The case managers and social workers from Bassett Healthcare Network understand this and often help patients resolve non-medical issues to improve health outcomes. In one example, a patient was being admitted to the hospital multiple times for recurring infections due in part to having no electricity or running water to comply with post-discharge instructions. Bassett staff enlisted community support that secured temporary housing, made alterations to the home so that it would be safe and habitable, and assisted the patient with his care regimens and medical appointments. This patient has not been readmitted since.

In another circumstance, a diabetic patient was being readmitted multiple times because he couldn't afford the cost of medical appointments, insulin, and other medications. Staff at Bassett assisted this patient by accessing a hospital fund that offers temporary assistance to qualified patients and also helped the patient apply for Medicaid. This patient can now afford medical appointments and medication and has not been readmitted since.

This case study is part of the NYS Triple Aim series highlighting how New York hospitals are improving health, enhancing quality and reducing costs. Hospitals, nursing homes, and home care agencies across New York State are pursuing the Triple Aim. In spite of fiscal constraints, its members are embracing the challenge of transforming health care and are implementing new and innovative approaches to delivery.