Preventing readmissions and shortening the time to do preadmission screenings is very important to Northeast Rehabilitation Hospital located in New Hampshire since the hospital specializes in stroke and traumatic neurological injuries very often resulting in timely and complex patient transitions.
When Patricia Buiocchi, joined Northeast Rehabilitation Hospital, as Vice President of Business Development and Strategic Planning, she was surprised to find liaison clinicians spending most of their day doing data entry work as part of pre-admission screening. The team handles referrals for two acute hospitals with a third on the way, 23 outpatient facilities, and a home care service in southern New Hampshire and northern Massachusetts.
One of Buiocchi’s first moves as was to turn to Curaspan’s “ReferralCentral” a web based referral management software to speed up the process. By using the software, it no longer takes hours of phone calls, emails, and faxes to communicate and find the answers to specific questions.
“It used to take liaisons two hours to input information for each incoming patient. By using “ReferralCentral”, data is delivered in a complete legible referral package. As a result, referrals have jumped 15 percent in 12 months.
In another case, Laura Davie, Project Director for the University of New Hampshire Institute for Health Policy and Practice, has been working with community partners on behalf of the New Hampshire Bureau of Elderly and Adult Services to develop and implement a long term patient-centric hospital discharge planning model to discharge individuals back into the community and hopefully prevent unnecessary readmissions.
Specifically, several models such as the “Better Outcomes for Older Adults through Safe Transitions” (BOOST) and “Care Transitions Intervention” (CTI) developed at the University of Colorado Denver are used to help patients when they are discharged.
New Hampshire’s ServiceLink Aging and Disability Resource Centers are supported by a strong technology-based infrastructure and a team-based approach for operations management. They operate as a single point of entry for all long term care and the transitions specialists provide follow up support intended to prevent readmissions.
Using technology such as the BOOST model enables ServiceLink staff to follow discharges with individuals in high need of social support, and follows patients with complex medications and needs. Under the CTI model, transition coaches are trained to help individuals identify goals and problems but the coaches don’t provide direct medical care to the patient when they leave the hospital
In addition, a workshop held in New Hampshire has been organized that includes three hospitals, three ServiceLink Aging and Disability Resource Centers, several community and case management agencies covering three counties, to support individuals so that they can make informed choices and find access to long-term support including a wide range of in-home, community-based, and institutional services and programs.
