Elizabethtown Community Hospital is reducing hospital readmissions with their Care Transitions Program. This program ensures all patients are provided with a full continuum of care when they are discharged from the hospital. Every patient is called 24 to 72 hours after being discharged and assigned a Care Transitions Coach as needed. The Care Transitions Coach makes home visits, coordinates community services, and provides medication support for those patients at risk for readmission.
A Community-Based Care Transitions Committee, made up of 21 service agencies within the neighboring five counties, supports this program by providing key referrals for the supportive services needed by discharged patients. The efforts of the Care Transitions Program resulted in a 6% decrease in all-cause hospital readmissions in 2013.