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Stopping the Revolving Door: Montefiore Care Management's Care Transition Program

The Joint Commission has indicated a need for a more effective transition of care for patients across the continuum of care. Ineffective transitions of care have led to adverse events and higher hospital readmission rates. CMO, Montefiore Care Management, has created a Care Transitions Program at the point of discharge to ensure post hospital care and transitions across all care settings are coordinated, appropriate, effective and efficient and to further evaluate patient knowledge of self-management needs.

Literature has shown that some of the barriers to effective transitions of care include communication breakdowns, patient education breakdowns, and accountabiity breakdowns. Early research of care transtions model have illustrated that programs that have timely follow up, support and coordination after the patient leaves a care setting enhances patient's quality of care and reduces admissions.

The Care Transitions Call Program is staff by RN Clinical Coordinators and LPN Care Management Analysts who utilized the following process across all transitions across the care setting: Screening, Self-Care Management Assessment, Inteventions: Patient and Care-giver engagement and empowerment, Integration of member information systems, and transitioning to Intervention teams and finally the development of care plan by identification of problems, goals and interventions. Outcome measures utilized for the program include: decrease in unplanned admissions and readmissions, increase in compliance with routine and scheduled PCP visits within 7-10 days of discharge and increased medication adherence. This program illustrated a drop in the 30-day readmission rate across all lines of business from 19.4% to 11.8%.

Obj. 1:  Discuss and understand the barriers to effective transitions of care across the continuum of care
Obj: 2: Discuss care coordination strategies utilized by the Care Transition program to improve communication and patient education while maintaining accountability to the patient’s plan of care
Obj. 3:  Discuss the continual assessment of outcome measurement of the Care Transition Program to ensure goals of the program of decreased admission, increased patient satisfaction and improved quality of care were met.