Improving Care Transitions Across a Community

Transition coaches may be the “glue” between hospital visits and primary care. So says Julie Cann-Taylor, COO of Wyoming Medical Center in Casper. The 191-bed rural hospital participates in a statewide collaborative to improve care transitions and has five transition coaches who assist patients and families during an episode of illness. This project focused on 10 diagnoses and has helped reduce readmissions for acute myocardial infarction, congestive heart failure and pneumonia. Partnering with public health and community organizations has been important in the follow-up across care settings. Wyoming Medical Center also is building more primary care practices, then bringing them in to work with the transition coaches. Cann-Taylor foresees coaches taking patients to their first doctor's appointment after hospitalization and doing care planning with patients in the community—moving beyond handling just hospital discharge.

For more information, contact Cann-Taylor at jcann-taylor@wyomingmedicalcenter.org or Dina Kamboris-Betts, executive director of care management services, at dkamboris-betts@wyomingmedicalcenter.org. More case examples on care coordination and community health are available on HPOE.org and on the Association for Community Health Improvement website at www.healthycommunities.org.