Readmissions continue to present an especially critical problem to healthcare providers. Hospitals are held accountable for the patients after they are discharged. Many hospitals have no idea what is happening to them or where they are once they leave the 4 walls of the medical facility. However, they are keenly aware of the importance of reducing readmission of these patients. At the beginning of fiscal year 2015, the CMS readmission penalties rose to 3 percent for patients with originally specified conditions.
As a result, hospitals today are seeking true partners in the community that have knowledge and experience in Post-Acute Management Healthcare. Transition Care of America (TCA), formerly a division of Specialized Nursing Services (SNS), specializes in post-acute care management services, specifically, transition care services to prevent readmissions …
Nancy Rubio, Chief Network Development Officer for Transition Care of America says, “With the assistance of TCA, it absolutely is possible for a hospital to manage its high risk, high acuity patients as they are in the process of discharge and after they have returned to the place they call home.”TCA has proven this ability to lower readmission rates over the past three years in four Broward area hospitals. During the first quarter of 2015, the company followed 250 patients and reported a return of only 17 patients to the hospital. That is a 6.8% readmission rate for those patients that had been identified as “high risk” for readmission. The patient population included the uninsured, Medicare insured and all conditions.
Every hospital has a personality. TCA drills down on the hospital’s individual needs due to geography, demographics, specific readmission rates and identification of problematic conditions. Not every hospital sees patients with the same diagnoses returning. Specialty hospitals performing special procedures have a different return population than a County hospital. “A real bonus is the fact that we will work with any diagnosis in addition to those stipulated by CMS: myocardial infraction, heart failure and pneumonia, total knee replacement and total hip replacement. It makes a real difference in the eyes of our partners,” adds Rubio.
TCA uses a proven set of techniques with each patient that has worked: reconciliation of medication; education about the disease; management of nutrition and diet; development of sensitivity to red flags, instruction in self-monitoring; connection to resources in the community. Every patient has a hospital coach and more importantly a Home Coach, an advocate to whom they have access 24/7 for all needs!
To demonstrate that, Transition Care of America now is offering SFHHA members the opportunity to test the “Post-Acute Patient Management Service" during a one month free trial. ”We believe in the transitional care model and that the case management services TCA offers will benefit both providers and their patients,” Rubio concludes.
