Healthcare professional engaged in discussion during the Sioux Falls readmission round table event.

After a stay in the hospital, the majority of patients will transition home while others may enter a skilled nursing facility. Each individual’s journey back to health comes with challenges and requires a coordinated effort of family, friends and healthcare professionals. Reducing patient risk and monitoring care during a transition will prevent a return to the hospital.

“While communication and education are offered at discharge, follow-up care and medication can be confusing,“ explained Linda Penisten, RN, OTR/L, program manager for Great Plains Quality Innovation Network (QIN). “Healthcare facilities are taking steps to find solutions and reduce the number of patients returning to the hospital.”

Great Plains QIN is hosting thought-leaders and healthcare professional in three communities across South Dakota in a guided discussion on how to make the transition from hospital to home a safer transition.

Let’s Not Re-invent the Wheel: A Patient-Centered Approach to Preventing Readmissions is a roundtable forum to explore the three key topics related to readmission: care transition, opioid use and super utilizers. There are numerous reasons why an individual may be readmitted to the hospital, including miscommunication, adverse drug events, complications from chronic disease and lack of patient engagement. The round table is an opportunity to consider the risk to patients entering this critical period of care and review practices to decrease that risk.

Facilities are utilizing data and improving patient-to-provider and provider-to-provider communication. Case managers, social workers and community partners also play a key role coordination of care from hospital to home. Penisten added, “There are new procedures, policies and communication to make it safer for patients to transition home. We don’t need to reinvent the wheel, but let’s talk about how the wheel of care transition has been updated.”

The first group of healthcare professionals met in Sioux Falls on Tuesday, October 16, to identify high-impact opportunities and best practices for preventing readmission. Additional roundtables will take place in Rapid City on October 22 and in Aberdeen on November 6. Register today.

Improving care coordination leads to better patient outcomes, overall satisfaction and reduces avoidable hospital admissions. Great Plains QIN partners with communities throughout the region to unite stakeholders, consumers and healthcare providers to improve communication and care coordination resulting in reduced hospital admissions, readmission and medication harm.