HANYS case studies
Cortland Regional Medical Center’s Transitional Care Program is working to reduce 30-day readmissions for patients with congestive heart failure and chronic obstructive pulmonary disease. The program utilizes concepts and tools from programs such as “Transitions Intervention” and “Project RED” (Re-Engineered Discharge) to help patients as they transition care settings. This includes providing a Registered Nurse Transitions Coach to:
- Facilitate interdisciplinary collaboration and care continuity;
- Encourage patient and caregiver participation in the care plan; and
- Work with staff at a nearby cardiologist office to provide early interventions and hospital admission prevention efforts.
In addition, home health nurses visit patient’s homes within 72 hours after they are discharged to answer questions and support their transition. As a result of these efforts, Cortland Regional Medical Center has reduced 30-day hospital readmissions for congestive heart failure patients to 14.3 percent over the course of one year. For those specifically participating in this program (nearly 400 patients), the 30-day readmission rate for congestive heart failure patients decreased from 50 percent to 12 percent.
This case study is part of the HANYS Triple Aim series highlighting how New York hospitals are improving health, enhancing quality and reducing costs. Hospitals, nursing homes and home care agencies across New York state are pursuing the Triple Aim. In spite of fiscal constraints, its members are embracing the challenge of transforming health care and are implementing new and innovative approaches to delivery.
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