In 2014, there were 28 million patient discharges in U.S. hospitals. The Centers for Medicare & Medicaid Services estimates that in 2017, six million senior citizens were readmitted to hospitals, which cost an average of $15-20 million.

Delivering effective care to homebound patients carries a number of challenges — from scheduling aides to providing up-to-date care instructions to transmitting information back to the doctor’s office or hospital.

In facing these challenges, Kalispell Regional Healthcare (KRH), a network of three hospitals, 32 clinics, and 20 affiliated outreach clinics in northwestern Montana, weighed the benefits of a new system with the potential costs.

In 2014, Parkview Medical Center realized that it needed to reduce its readmission rate significantly while also fixing a communication gap between home health care agencies and other post-acute facilities. To address these issues, my director and a team of other leaders joined together to pilot a new transition care center that went live in 2016.