Best Practice Intervention Package - Kansas Foundation for Medical ...

INSIGHTSReducing ACH (whether readmissions or avoidable hospitalization) is theoverarching goal of our program. We have linked the following programs toachieve this goal:• Identification of patients at risk for rehospitalization: At the start of care,every admission is assessed for risk factors that could increase thelikelihood of rehospitalization (Use the ACH Risk Assessment- See theJanuary 2010 BPIP). Using our current technology, interventions havebeen built into our EMR to assist the clinician in developing the plan ofcare for at risk patients. Interventions include: Telephone monitoring,creating “My Emergency Plan”, utilization of available communityresources, and medication management.• Additional programs to support the patients and reduce rehospitalizationare:o Telehealth –offers the use of innovative technology to improveclinical outcomes while keeping patients safe at home.o Transitions in Care Program (TCM) – the goal of the TCMProgram is to improve self management of the chronic diseaseprocess. The program is a hybrid of the evidence-basedTransitional Care Model (TCM). TCM trained RNs utilizeevidence-based assessment tools to identify the patient’s ability,knowledge, and willingness to manage their chronic illness andtransition back to the community.o Chronic Navigation - A telephone support service implementedwhich provides personal navigation services for our chronically illpatients and their physicians to better coordinate care andimprove access to health care services. The service is supportedby Virtua.Diane Costanzo, RN, MSN, MSHA, CMSRN, CNA-BC Director of NursingVirtua Home Care West JerseyPat Quackenbush, BC-RN MBA Director Quality Management Virtua HomeCareRead the Virtua Home Care Success Story- 52 -