Patients transitioning out of an acute care setting are often at risk of readmission due to the complexities of the clinical and social factors impacting their post-acute care, including availability of post-acute care options, fiscal constraints, and patient and caregiver education. For patients with the greatest risk of readmission, Upstate University Hospital’s intensive transitions team (ITT) facilitates safe, effective, and smooth transitions.
Upstate University Hospital’s ITT is a multidisplinary, relationship-based team; they employ a “whole person” approach, actively following patients during their 30-day post-discharge transition, identifying ongoing care needs and concerns. They assist patient engagement with primary care and post-acute care providers and connect patients with post-acute partners for ongoing care delivery. ITT supports communication between patients, families, caregivers, and post-acute providers through warm hand-offs and a person-centered, cross-setting plan of care. They continually identify and address root causes of preventable acute care readmission.
Six months post-intervention, Upstate University Hospital’s 30-day readmission rate decreased 74%, inpatient discharges decreased 53%, and emergency department discharges decreased 20%.
For more information, contact Diane S. Nanno, MS, CNS, RN, Director, Transitional Care, Upstate University Hospital, at (315) 464-1964 or at firstname.lastname@example.org.