Innovation Spotlight - Triple Aim: New York Hospitals Are Improving Health, Enhancing Quality, and Reducing Costs.

South Nassau Communities Hospital Improves Elderly Care

South Nassau Communities Hospital recognizes the importance of efficient and safe processes in the transition of care from the hospital to the skilled nursing facility and nursing home. That’s why for more than four years, the hospital’s clinical leaders, including physicians, nurses, social workers, and care managers have been partnering with clinicians from over 25 local sub-acute facilities and nursing homes to share best practices.

Some of the initiatives South Nassau Communities Hospital implemented include: improved communication among clinicians as the patient moves from one care setting to another; follow-up phone calls to ensure successful transition of care and that standards are being applied; and sponsored, regular guest lectures on topics that enhance elderly care.

Through these initiatives, the hospital has had a reduction in readmissions, particularly among patients with chronic diseases, such as heart failure, pneumonia, congestive pulmonary obstructive disease, and the terminally ill.

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