Transitioning Elderly Patients from Hospital to Home

Grantee Name

Hudson Headwaters Health Network

Funding Area

Expanding Health Care Coverage

Publication Date

May 2011

Grant Amount

$44,835 for planning and $484,375 for program implementation

Grant Date:

February 1, 2008 – January 12, 2011

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In 2007, 18.5% of Glens Falls Hospital’s Medicare patients were readmitted to the hospital within 30 days of a hospital admission, compared to the national average of 15%–21% and the statewide average of 12.5%–15%.

These acute care readmissions are costly, often indicate a lack of care coordination, and threaten the financial viability of acute care institutions, especially under the provisions of Federal health reform. Hudson Headwaters Health Network (HHHN) and the Glens Falls Hospital proposed a collaborative approach to reduce hospital readmission rates among the Medicare population. Analyzing Medicare admissions from 2006, they discovered that 1,353 patients were readmitted within 30 days of a prior admission, representing 2,429 admissions. The resulting analysis indicated that 40% of the patients with specific medical conditions accounted for 80% of the admissions (542 patients). HHHN and Glens Falls Hospital focused on developing a program that targeted this population and more directly addressed patients’ needs.

A second NYHealth grant supported implementation and evaluation of this program.

Outcomes and Lessons Learned

Initiated a hospital-based screening tool for high-risk patients, which allowed patient assignment to an intervention or control group and execution of patient consent.
Coordinated care for the intervention group, including patient education, medication management and reconciliation, personal health records, patient and caregiver expectations, understanding of social and support needs, and ambulatory follow-up.
Introduced patients to an ambulatory transition coach who reiterated prior education, finalized the discharge plan, coordinated the transition to home, and provided follow-up services by phone and visits including repeat assessment.
Coordinated data flow, including availability of data for patient engagement, and financial analysis and potential engagement with managed Medicare firms

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