Editor's note: This popular story from the Daily Briefing's archives was republished on Jan 15, 2019.
To help older patients with chronic conditions transition from hospital to home, Aurora West Allis Medical Center (AWAMC) launched an innovative program with the West Allis Fire Department that not only cut readmission rates, but curbed overall hospitalizations and boosted patient satisfaction.
'Transition in Care'
The hospital in 2015 launched the program, called Transition in Care, after a three-month pilot showed a significant decline in the number of non-vital 911 calls for ED visits. The program, funded by the hospital, aims to cut readmission rates for certain high-risk Medicare beneficiaries, including those with diabetes, high blood pressure, or congestive heart failure.
In the program, AWAMC flags high-risk patients for the fire department, which then dispatches paramedics to check in on the patients within one or two days of their discharge from the hospital. Every patient participating in the program receives at least one home visit, AHA News reports.
During the home visits, paramedics—who have all received training on community-based health care at the University of Wisconsin-Milwaukee College of Nursing—check up on patients to make sure they understand their discharge instructions, know who their insurer is, fill their prescriptions, and have their follow-up appointments. The paramedics also ask about patients' daily needs, such as where they grocery shop, whether someone is able to shovel snow for them, or if they need any assistance installing precautionary items, such as a shower hand rail or toilet safety seat.
After the visit, the paramedics update nurses in the Transition in Care team about any follow-up care or services that may be required. The hospital incorporates all the data into the patient's EHR.
A successful program
So far, the medical center has enrolled 120 patients in the program. According to AWAMC, the program has contributed to a 20 percent decline in 30-day readmissions for the ED, as well as a 30 percent decrease in overall hospitalizations for participants.
Moreover, David Bandomir, a registered nurse and the mobile integrated health care coordinator for the city's fire department, said patient satisfaction is "off the charts." Separately, Brandon Foley, a paramedic involved with the program, said patients appreciate the hospital's role. "When we go into their home and say this is something the hospital is paying for because it is concerned about you, they just fall in love with the program," Foley said. "No [one] else provides free services like that."
And Pagel is confident that Transition in Care will prove to be a successful, long-term way to lower health care costs while improving health outcomes. "We know this is going to show good outcomes and we want to move the program forward," she said (AHA News, 5/23).
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