Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk

A discharge management plan that integrates community resources and programs can further ease the transition from hospital to home and improve continuity of care. This resource profiles two aptly named discharge management efforts that access and maximize partner resources for their populations. CHOICES is a hospital-based case management program for older adults in Albany, N.Y., while CASA (Community Alternative Systems Agency) in Broome County, N.Y. is a community-based initiative that collaborates with hospitals and nursing homes to help frail elders and young disabled adults. Both are client-centered models in discharge planning designed to meet the physical and psycho-social needs of their respective populations. In this 32-page special report, "Discharge Planning Primer: Community Collaborations to Decrease Hospital Readmissions Risk," Nora Baratto, manager of the case management department at St. Peter's Hospital's CHOICES program, and Michelle M. Berry, CASA director, describe the coordinated approaches central to their hospital discharge processes and the impact their programs have had on patients' outcomes and satisfaction, hospital readmission rates and healthcare costs. The CHOICES program has been so well-received that St. Peter s Hospital now makes it available to its own employees as an elder care benefit. And with readmission rates affecting quality and profitability, the healthcare industry is taking notice. In this special report, you'll also get a summary of more than 200 responses to a non-scientific e-survey conducted in 2007 by the Healthcare Intelligence Network on how healthcare organizations are working to reduce hospital readmissions. Ms. Baratto and Ms. Berry share details on the comprehensive assessments, home visits, transition planning, and collaborative partnerships that are integral to their discharge management processes. They provide details on: -Overcoming barriers between the health system and community; -Successfully transitioning patients from one care setting to another; -Identifying patients at risk for readmission; -Forging collaborations with emergency room staff, inpatient staff, community physicians, and community agencies during discharge planning; -Educating clients, family and caregivers on care access and appropriate use of health resources; -Developing a home visit checklist for comprehensive assessments of patient condition; -Benefits gained and lessons learned in the discharge planning process; and much more.