Hospitals in pursuit of excellence

Patient-Centered Care Coordination

Patient engagement is paramount to reducing readmissions and improving quality of life. That’s what is driving Beebe CAREs, launched in 2012 by Beebe Healthcare, based in Lewes, Del. Patients establish goals, framed not by a physiological measure but by a life event or activity: attending a child’s high school graduation; attending a NASCAR race; visiting the Boardwalk with a grandchild. Participants—in most cases, high utilizers in the health care system—are assigned to an RN and supported by a multidisciplinary team with a nurse practitioner and social worker, all trained in health coaching. The team meets with patients in the hospital before discharge and conducts a full bio-social assessment. After discharge, a social worker follows up, and the team coaches patients for 90 days wherever they are—at home, in a skilled nursing facility or—if the patient is homeless—meeting in a local shelter, restaurant, church or library. The program has helped Beebe reduce readmissions 39 percent. In addition, based on the Care Transitions Measure, patients’ transition skills have shown a four-fold improvement. Quality of life has increased more than two times, based on the CDC’s BRFSS survey. Beebe is working to expand the program through its primary care practices across Sussex County.

For more information, contact Megan Williams, DNP, director of population health, at mwilliams@beebehealthcare.org. 

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