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OSF deploys care transition program, reduces readmission rate from 29% to 9%

Healthcare It News

OSF HealthCare, a health system that serves Illinois and Michigan, had a big challenge: Managing the high rate of patient readmissions from hospitals to skilled nursing facilities and eventually to home care. THE PROBLEM This issue stemmed largely from gaps in continuous care during transitions between these settings.

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Fixing The Hospital-To-Home Health Care Transition

Home Health Care

“On hospital discharge and transition to the next level of care, older adults continue to face risks such as miscommunication, gaps in care and medication-related issues,” the researchers wrote. Transitional care models are designed to address these challenges with the primary aim of preventing readmissions.”

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California and Ohio Advancing Equity for Older Adults and Family Caregivers

NASHP

The Master Plan also aligns with some of the governor’s key initiatives, such as the “California for ALL” vision and the Task Force on Alzheimer’s Prevention and Preparedness. Key findings of the Summary Assessment highlight inequities preventing Ohioans, especially older Ohioans, from living a long and full life.

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State Community Health Worker Models

NASHP

ACO Accountable Care Organizations. CBCM Community Based Care Management Program. CDC Centers for Disease Control and Prevention. PH-MCO Physical Health Managed Care Organization. USPSTF United States Preventative Services Task Force. APM Alternative Payment Model. CBO Community Based Organization.

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Supporting the Continuum of Care for Serious Illness in Medicaid Managed Care

NASHP

People with serious and life-threatening health conditions experience care needs that drive costs, including hospital admissions , emergency department utilization , and nursing home care. billion on chronic obstructive pulmonary disease (COPD) per year.

Medicaid 102
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Community Health Worker Models

NASHP

CHW services could be used for many health conditions as long as there is a care plan in place written by a physician, physician assistant, nurse practitioner, or a certified nurse midwife. Many provider types may supervise CHWs, including physicians, dentists, public health nurses and mental health professionals among others.