Skip to main content
Past Event Sticker

NCD Pacing Event: Part One of Two: Improving Readmissions Through a Comprehensive Approach to Discharge Planning and Care Transitions

Business Audience Diverse Business Group
Top

Thursday, August 15, 2019, 10:00 a.m. to 11:00 a.m. PT.

This HIIN and Hospital Pacing Event will serve as the first in a two-webinar series to discuss best practices in discharge planning and care transitions that support the patient’s next steps as strategies to impact readmissions. This part one event will feature the work of the SUNY Upstate University Hospital to implement and evolve a program designed to impact readmissions through supported care transitions, including providing support to address patients’ needs, facilitating next steps with care partners, and implementing structured communication strategies across care settings. Results such as reduced readmissions, admissions, and ED utilization will be shared.  In addition, Tuft Medical Center will discuss its work to learn from patients’ perspectives about their readmissions, including results related to communication and the management of post-acute care needs.

Summary from 8/15 Pacing Event: “Part 1 of 2: Improving Readmissions through a Comprehensive Approach to Discharge Planning and Care Transitions”

As HIINs continue to work with their partner hospitals to impact readmissions, opportunities exist to fully leverage and improve understanding of best practices in discharge planning and care transitions. A comprehensive approach to discharge planning and managing care transitions that support the patient’s next steps includes identifying and addressing the needs of patients; managing transitions in alignment with varying levels of risk for readmission; leveraging strong relationships and ensuring clear communication about patients with post-acute care partners; and having meaningful communication with patients and their family members.

This session featured the work of SUNY Upstate University Hospital to implement and evolve a program designed to impact readmissions through discharge planning and supported care transitions, including providing support to address patients’ needs (e.g., transportation, medications), facilitating next steps with care partners, and implementing structured communication strategies across care settings. Results such as reduced readmissions, admissions, and ED utilization were shared. Tufts Medical Center discussed its work to learn from patients’ perspectives about their readmissions, including results related to communication and the management of post-acute care needs.

The guest presenters for this event were:

  • Diane Nanno, MS, CNS, RN, CCTM, NE-BC, Director of Transition Care Services at SUNY Upstate University Hospital (Vizient HIIN), who discussed her work to design and implement the hospital’s Intensive Transition Team (ITT), which leverages community partnerships and relationship-building with patients and their families to support patient-specific needs prior to, during, and after discharge to reduce hospital readmissions, admissions, and ED utilization, among other outcomes.
  • Amy LeClair, PhD, Health Services Researcher and Assistant Professor at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center (Vizient HIIN), who discussed her team’s interview-based approach to identifying patient-reported contributing factors to readmissions and some of the themes resulting from this work around the contribution of communication, as well as the appropriate matching of patient needs to post-acute care services.

The session was moderated by Kendall Hall, MD (NCD).

Audience/State: