PP103 – Reducing Hospital Readmissions Across a Large Organization With a Multi-discplinary Transitional Care Management Navigation Team
At Northwell Health, the 14th largest healthcare system in the United States, our intention in reducing readmissions across our 23 hospitals is to deliver patient centered best in class care. In an aim to reduce the suffering and improve the well-being of our patients, we recognize that our responsibility to the patient extends beyond the day of discharge. Northwell is committed to being deserving of the faith and trust of our patients by protecting them from unnecessary illness while in our care. Success in reducing medical readmissions depends on multiple factors including a strong commitment to clinical excellence from our hospital partners and a strong transitional care management program to help patients transition back to the community post hospitalization.
In 2014 Northwell Health established Health Solutions, the Care Management/Population Health arm of the organization. Health Solutions utilizes robust analytics based on data sets obtained internally and from a combination of governmental and commercial payers. This is combined with a highly developed clinical deployment strategy which includes 4 years experience in navigation with an advanced model of integration between lay, social work, RN, and advanced practice navigators as well as collaboration with care management services, governmental agencies and programs, and clinical services. Additionally, Health Solutions has developed the IT infrastructure to connect and follow patients in real-time insuring the access to real time and historical health information that leads to the achievement of outcomes. As well as co-developing a HIPPA secure texting platform that helps communicate with patients during their transition.
With the clinical redesign done with our hospitals and the transitional care management team structure led by advanced care providers that has been able to be established we have been able to reduce readmissions with a 10% delta in the medical populations including COPD and PNA.
1. Learn how to build a transitional care management program that translates across a diverse population of patients
2. Understand the impact of increasing hospitalized patient care quality by reducing re admissions
3. Understand the importance leveraging technology to help navigate patients through a transition of care