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Provider Interventions and Tools

CMS is targeting readmissions to the hospital within 30 days of discharge as a probable marker for both poor quality of care and wasted reimbursements. There are multiple reasons for readmissions. Providers are paid for providing separate services, so care is often fragmented. In addition, many patients aren’t seen by physicians promptly after discharge. Medications are not reconciled between settings, which can ultimately send patients back in the hospital. Discharge summaries from the hospital aren’t going to the doctor fast enough to be useful in the immediate post-discharge period.

Coaching has successfully helped patients transition back into the community and improve patient self-management. Patients receive a pre- and post-discharge visit, along with a few phone calls, to reinforce self-care management skills. The results of this special study, Eric Coleman’s Care Transition Intervention, resulted in hospital readmissions reduced by 50% at 60 days post discharge.

Eric Coleman's Care Transitiion Intervention