Moving Forward with Transitions of Care: Improving Readmission Rates

On May 1, 2019, the Transitions of Care program launched as a partnership between CHI Saint Joseph Health and CHI Saint Joseph Health Partners Clinically Integrated Network (CIN) in the Central/East market. The program offers a 60-day follow-up service for select patients to ensure access to resources, to reduce health care barriers, and to prevent readmission.

Pam Thompson, RN, BSN

Pam Thompson, RN, BSN

How do providers know if their patient qualifies for the program?

Your patient may qualify for the Transitions of Care program if they have:

  1. An included diagnosis-related group (DRG): CHF, AMI, CABG, PNE, COPD, TKA/THA)
  2. A readmission risk score of at least 48 or a case management referral.

If a patient meets these qualifications, then he or she is eligible for the program regardless of the payer source.

How does the Transitions of Care team help patients and providers?

The Transitions of Care Team consists of dedicated group of RN health coaches and social workers. The team strives to meet and greet eligible patients before they leave the hospital to begin developing a quality relationship. Once a patient is discharged from the hospital, the team works for the next 60 days to serve as a valuable resource to the patient. The health coaches and social workers will not only check in weekly with patients, more often if needed, but are also available to proactively answer questions about medications, assist with scheduling appointments, educate the patient on the illness/disease, and even schedule home visits. The team serves on the frontline as a source of immediate support for patients to help patients heal and prevent readmission. The program is showing improvement with 30-day readmission rates.

To learn more about Transitions of Care, please contact Pam Thompson, RN Health Coach, by phone at 859.321.3391, or via email pamelathompson@sjhlex.org.