A collaborative effort aimed at reducing hospital readmission rates for high-risk patients
Salisbury, NC, July 22, 2015 - Novant Health Rowan Medical Center is partnering with Rowan County Emergency Medical Services (RCEMS) to provide transitional care to patients who are at a substantial risk for hospital readmission. This innovative partnership will allow Novant Health to collaborate with county emergency medical services to provide post-discharge and preventive care for its patients. The program goes live Aug.1.
Novant Health Rowan Medical Center was selected by the North Carolina Quality Center as one of 15 hospitals to participate in its care transitions program. The Duke Endowment, in partnership with the North Carolina and South Carolina hospital associations, is funding the program through a $5 million grant in an effort to improve care transitions.
"It is our hope that as we improve patient care and outcomes, the lessons learned through this initiative will be shared with healthcare systems throughout the Carolinas," said Mary Piepenbring, vice president of Health Care at The Duke Endowment.
The grant, totaling $251,855 over the span of a two-year period, will facilitate the hospital's work with RCEMS to provide more thorough post-discharge care for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in their own homes. Patients with these conditions are typically in and out of the hospital, making them a priority for preventive care.
"We have a very close relationship with RCEMS," said Dari Caldwell, president of Rowan Medical Center. "They have wanted to do something like this for a while, and this grant is the perfect opportunity to fulfill that." Caldwell noted that RCEMS is a progressive, innovative group that is always looking for opportunities to improve the health and quality of life of Rowan County citizens.
The idea behind the care transitions program is better care after discharge in order to reduce a patient's likelihood of hospital readmission. Patients will be given a detailed assessment of post-hospital needs by their hospital-physician team, while RCEMS will ensure post-hospital care follow-ups by way of home visits and detailed one-on-one education to help facilitate patient learning.
"Up until now, we have not had the resources to do anything like this," said Caldwell. "We're hoping that this process will help our patients remain healthy longer and experience less deterioration so that they can have more healthy days."
Lennie Cooper, RCEMS division chief, said that the program benefits RCEMS by reducing the volume of 911 calls from high-risk patients and by keeping them healthy longer. RCEMS receives roughly 15,000 calls a year and has eight 24-hour ambulances.
"We expect to visit about 165 patients in the first year, with each patient getting around four visits," he said. "The patients we will be visiting are most likely high frequency users. By visiting them on a scheduled basis and making sure that they're taking proper care of themselves by following medication routines and following through with their discharge instructions, our hope is that we won't see them back so soon."
CHF and COPD patients will undergo a risk assessment before being discharged from the hospital to determine the severity of their condition and thus their priority of preventive care. Patients will receive a call from their care coordinator within 48 hours of discharge to review instructions, assess ability to manage medications, as well as ability to comply with the discharge treatment plan.
RCEMS paramedics will provide further assessment and enforcement of post-discharge care by way of their home visits. The hospital will identify patients who have chronic illnesses, and some patients can expect a visit from RCEMS in as little as three days after leaving the hospital.
The transitional care program allows paramedics to closely monitor these high-risk patients' conditions and address a problem before it becomes a medical emergency, usually resulting in a 911 call.
"We feel that Rowan County is a great incubator for new programs like this," said Caldwell. "We are large enough in size to be significant, but we are also the right size to test new programs and be able to manage them," she said. "We are excited about this opportunity and feel blessed to have been selected."
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