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I attended a meeting where our speaker was from the Care Transitions Program, which is funded by the Affordable Care Act.

I was so excited about the program I thought I would share it with my readers.

This is a pilot program that helps seniors who are being released from a hospital stay prepare for their release, and most importantly, stay out of the hospital. The program is patient and caregiver centered, and is a 30 day program. It’s designed to save both the hospitals and the Medicare Program money, because re-admissions are very expensive.

The program targets Medicare Beneficiaries with a number of chronic conditions who are at high risk for readmission to the hospital after discharge. In San Diego the program is a partnership with all of our non-profit hospitals, (Scripps, Palomar, Sharp, and UCSD) who each have their own systems for working with the program.

The goal of the program is to reduce the number of re-admissions by 20% per year, which will result in annual savings in San Diego by over twelve million dollars.

There are five major causes of hospital readmissions that the program targets. Those are:
1. Inadequate or inconsistent continuity of care coordination and hand of downstream providers within hospital systems
2. Inadequate medication education and reconciliation
3. Lack of patient or caregiver activation
4. Insufficient connections to social supports
5. Lack of disease management for patients with chronic illness

I order to assist with these five major causes, the patient gets a personal health care coach, who helps them by holding their hands through a complex system. This includes completing forms for the family, not just sending names and numbers in the form of a “referral”.

Through this process, both the patient and the family learn self-management skills that can assist them with their health.

The focus of the San Diego Care Transitions Program is on what they call Four Pillars.

Those are

  1. Medication Management
  2. Patient Centered Record
  3. Physician Follow up and
  4. Knowledge of Red Flags

By working with the hospitals, they have been able to find areas of hospital systems that can be changed to create better patient outcomes. One system change in one hospital was simply waiting for discharge until the physician was able to get his or her notes into the system so that the discharge notes showed up before the patient was actually discharged.

The key elements of the San Diego Care Transitions Program are:

  1. The referral Process (hand holding, not just a name and number)
  2. Visit with the patient in the hospital before they are discharged
  3. Phone call to the patient after discharge
  4. Home visit within 2 days of the discharge
  5. Phone calls to the patient 7 days and 14 days after the home visit

The San Diego Care Transitions Program is a pilot program and is designed for people who are not on a managed care (Medicare Advantage) program. For more information please contact the San Diego Health and Human Services Agency.

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