Dream Partnerships in Health Care

If you build a community of care, people will come. It happened when Middlesex Hospital, in Middletown, Conn., began meeting with community partners. The objective: to work collaboratively to improve the hand-off process for heart failure patients being discharged to skilled nursing facilities and home care agencies. The 275-bed hospital had four partners in 2010; it has 39 partners, which includes 18 SNFs, in 2013. The hospital standardized patient and staff education, identified best practices and developed nurse-to-nurse reports to SNFs. A hospitalist who bridges care works at the SNF an average of eight hours each week. Data are tracked and reviewed constantly. The community partners meet monthly to review readmissions and discuss improvements. Results include improving the percentage of complete and accurate lists of medications received in the transition from hospital to SNF from 83 percent to 100 percent, and reducing readmission rates by nearly 8 percent. Next steps include standardizing education for COPD and improving antimicrobial stewardship.

For more information, contact Terri Savino, quality improvement coordinator. Middlesex Hospital participates in the AHA/HRET Hospital Engagement Network.