Following patients after discharge from the hospital can lead to better patient outcomes and fewer or less expensive readmissions. United Memorial Medical Center in Batavia, in collaboration with the WNY P2 Collaborative and the Genesee County Office for Aging, have partnered to identify and follow patients admitted to the hospital with congestive heart failure, chronic obstructive pulmonary disease, and pneumonia, because these patients are at risk for frequent hospitalizations and readmissions.
The program reaches out to these patients and provides no-cost, in home services to strengthen the outpatient management of these chronic diseases. Services include providing scales for tracking weights, colanders for measuring fluids, dietary education, and medication review. As a result of this program, patients have been less acutely ill, requiring fewer resources during subsequent admissions. The program has been initiated for Medicare patients, but is in the process of being expanded to all patients with these diagnoses.