On September 6, MedCityNews reported that hospitals and community groups are working to improve transitions of older patients when they are discharged from a hospital by strengthening communication with doctors and tracking them across health systems. Why? A lack of access to medication, transportation, food or equipment needed for recovery can sometimes land them back in a hospital.
“Just because they have had four days in a hospital doesn’t mean they are better,” said Mary Naylor, a gerontology professor at the University of Pennsylvania School of Nursing. Many of these patients also don’t have relatives or caregivers to help with tasks they were able to perform before they were admitted. “There are gaps in care, there are gaps in communication, there are gaps in adequate preparation for patients and families,” Naylor said. Programs being developed to help fill these gaps provide meal delivery, transportation, social services, help patients manage medications, schedule follow-up appointments, and look for signs of trouble. Read more
Care coordination is identified by the Institute of Medicine (IOM) as a key strategy that has the potential to improve the effectiveness, safety and efficiency of the American healthcare system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers and payers.
Our Efforts
Improving care coordination leads to better patient outcomes, overall satisfaction and reduces avoidable hospital admissions. Great Plains QIN is partnering with communities throughout the region to unite stakeholders, consumers and healthcare providers to improve communication and care coordination – resulting in reduced hospital admissions, readmissions and medication harm. We are focusing on processes of care at a community level to engage providers and stakeholders across the continuum of care. We are specifically working with communities that focus on Medicare consumers of greatest need, such as individuals with multiple chronic conditions taking multiple medications, consumers with behavior health issues, those dually-enrolled in Medicare and Medicaid, rural populations and individuals impacted by other social determinants of heath.
For more information on our efforts and to join our large community of committed providers, join our Learning and Action Network. Learn more!