Improving care coordination with a transition care center

Posted by Linda van Loon, RN, BSN on September 6, 2018

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.

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Topics: Population Health, Patient Engagement, Patients, Care Coordination

What the proposed 2019 MACRA changes mean for you


Developing standards for healthcare is nothing new — in fact, you could say the concept of identifying quality measures started in the early 17th century, when a Hungarian Doctor, Ignaz Semmelweis, championed handwashing in his clinic.

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Topics: Government Regulations, MACRA, Healthcare IT, Patients

How evidence-based clinical documentation gives time back to nurses


 As nurses, we know that patient care is not one-size-fits-all. Every patient has unique needs when it comes to determining the best course of treatment. But even with all of those unique patient needs, clinical documentation can be structured so that each patient gets the right individualized care while nurses use a standardized reporting system, ultimately saving nurses’ time.

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Topics: EHR, Nurse, Implementation, Patients

4 ways to improve and maintain a quality patient experience


All industries are having to adjust to the increasing power of customer voices and on-demand consumer trends. In the world of healthcare, this makes patients the decision makers who hold the most important perspective.

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Topics: Patient Engagement, Patient Safety, Patients

Thought Leader Podcast Series: Social Determinants of Health and Transitional Care


In the latest installment of our thought leader podcast series, I chat with Billie Lynn Allard, MS, RN, and Jennifer Fels, RN, MSN, co-founders of Southwestern Vermont Medical Center's transitional care program. Allard and Fels explain how they designed a program that addresses recurring gaps in care caused by social determinants of health in their rural community. 

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Topics: Population Health, Patients, Social Determinants

Tips to prevent readmissions using your EHR


The first of the 78 million baby boomers turned 70 last year, and the rest will do so in the next two decades. This aging population and an increase in chronic disease leads to rising readmission rates. And an industry emphasis on population health and patient engagement makes the need for reducing readmissions all the more important. Striving to reduce readmissions and keep patients healthy outside the hospital walls will further drive the shift from hospitals and nursing homes to care in the home, and from treatment to proactive care and monitoring.

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Topics: Home Care, Nurse, Patients

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