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Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk
Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk
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Like the convenience of a PDF file, but still like to receive a hard copy of this book? Order both versions and save 35 percent!

Coordinated planning of a patient's care following a hospital or nursing home stay can greatly affect health outcomes, likelihood of readmission and/or emergency room visits, as well as cost to patients, providers and insurers. A discharge management plan that integrates community resources and programs can further ease the transition from hospital to home and improve continuity of care.

Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk profiles two aptly named discharge management efforts that access and maximize partner resources for their populations. CHOICES is a hospital-based case management program for older adults in Albany, N.Y., while CASA (Community Alternative Systems Agency) in Broome County, N.Y. is a community-based initiative that collaborates with hospitals and nursing homes to help frail elders and young disabled adults. Both are client-centered models in discharge planning designed to meet the physical and psycho-social needs of their respective populations.

Part of the Reducing Hospital Readmissions Toolkit, a four-volume set with case studies from a variety of programs aimed at reducing unnecessary hospital readmissions, from discharge planning, transition coaching, transitions in care case management, medication reconciliation, community partnerships, home visits, assessments to identify high-risk patients and patient and caregiver education. Click here to save 25% when you order the Reducing Hospital Readmissions Toolkit.

In this 32-page special report, "Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk," Nora Baratto, manager of the case management department at St. Peter's Hospital's CHOICES program, and Michelle M. Berry, CASA director, describe the coordinated approaches central to their hospital discharge processes and the impact their programs have had on patients' outcomes and satisfaction, hospital readmission rates and healthcare costs. The CHOICES program has been so well-received that St. Peterís Hospital now makes it available to its own employees as an elder care benefit.

And with readmission rates affecting quality and profitability, the healthcare industry is taking notice. In this special report, you'll also get a summary of more than 200 responses to a non-scientific e-survey conducted in 2007 by the Healthcare Intelligence Network on how healthcare organizations are working to reduce hospital readmissions.

Ms. Baratto and Ms. Berry share details on the comprehensive assessments, home visits, transition planning, and collaborative partnerships that are integral to their discharge management processes. They provide details on:

  • Overcoming barriers between the health system and community;
  • Successfully transitioning patients from one care setting to another;
  • Identifying patients at risk for readmission;
  • Forging collaborations with emergency room staff, inpatient staff, community physicians, and community agencies during discharge planning;
  • Educating clients, family and caregivers on care access and appropriate use of health resources;
  • Developing a home visit checklist for comprehensive assessments of patient condition;
  • Benefits gained and lessons learned in the discharge planning process;
  • and much more.
PLUS, this report contains:
  • Details on new practices in hospital discharge instructions and in-person, print and telephonic initiatives underway industry-wide to pare hospital readmission rates;
  • 14 pages of Q&A that offer practical strategies for coping with non-compliant patients, culturally diverse populations and breakdowns in the discharge process.

This report is based on a 2007 audio conference on best practices in hospital discharges to reduce preventable readmissions.

Table of Contents

  • St. Peterís CHOICES Program Breaks Down Barriers to Care
    • CHOICES Provides Collaborative Approach
    • Services Provided by CHOICES
    • Significant Referral Sources
    • CHOICES Program Outcomes
  • Broome County CASA: Discharge Planning via Community Collaboration
    • The Importance of Community Collaboration
    • Getting the Frail and Disabled Home
    • Lessons Learned in Discharge Planning
  • 2007 HIN Survey Results: How Health Plans and Hospitals Are Preventing Readmissions
  • Q&A: Ask the Experts
    • Case Managers as Educators
    • CHOICES Program Outcomes
    • Data Supports the CHOICES Program
    • Addressing Breakdowns in the Discharge Process
    • Education & Effective Questioning Reduces Readmissions
    • Walking Through a Home Visit
    • Physician Feedback on Program Extremely Positive
    • Home Visits by Practitioners
    • Handling Young Disabled Adults
    • Discontinuing Care for Non-Compliant Behavior
    • Measuring Outcomes & Utilizing Trend Data
    • Community Partnering Critical
    • Meeting the Needs of Immigrants & the Homeless
    • Translators for Cultural Issues
    • Helping the Homeless Access Medicaid
    • A Guest Book for the Homebound
    • Working with Managed Care
    • Reviewing Cases to Avoid Readmissions
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: April 2008
Number of Pages: 32
ISBN 10: 1-934647-26-8 (Print version); 1-934647-27-6 (PDF version)
ISBN 13: 978-1-934647-26-4 (Print version); 978-1-934647-27-1 (PDF version)
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