Focus on Care Coordination

Delivering the right care, at the right time, in the right place. That focus is the strategy for preventing readmissions at Twin County Regional Healthcare in Galax, Va. The 141-bed rural hospital also focuses on four “must-haves” for patient discharge: follow-up appointments, home health services, prescriptions, and transportation for appointments. A multidisciplinary hospital team meets monthly to review readmissions, and care coordinators meet quarterly with skilled nursing facilities. According to Agnes Smith, CNO, “The key is pulling the team together and looking at readmissions. What populations are being readmitted? Start drilling down to see trends and identify chronic diseases.” Care coordinators educate patients on chronic disease management and match them to community services and agencies, including local pharmacies for assistance to buy medications. Respiratory therapists visit some patients at home after discharge, and area veterans volunteer to drive patients without transportation to follow-up appointments. TCRH has a goal of reducing readmissions to less than 7.6% and met that goal in December at 5.9%. In 2012, TCRH became part of Duke LifePoint, which “supports us 100% with resources and quality indicators,” says Jon Applebaum, TCRH president and CEO.

For more information, contact Smith at agnes.smith@lpnt.net.

HPOE.org has many more case studies and resources about improving care coordination and reducing readmissions.