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Break the Cycle of Rehospitalization by Optimizing Care Transitions Across the Continuum

Educational Session

June 13 @ 2:00 pm - 3:00 pm EDT

Traditional approaches to patient transitions from acute to post-acute care typically consist of the transfer of the patient, a stack of paperwork, little to no report, and limited interaction between settings. This can lead to unnecessary complications such as medication errors and preventable infections. The introduction of value-based payment models and penalties for hospital readmissions has motivated providers to improve transitions to post-acute facilities and home-based care, but challenges remain.

This session explains how post-acute analytics helps break down communication silos to connect healthcare organizations, optimizing transitions of care and patient management. Participants will learn how leveraging live data from their post-acute partners enables them to identify the most appropriate post-acute care setting based on the patient’s needs, enhance care coordination and patient education efforts, and define standards of care based on clinical pathways. Working together from the same data, acute and post-acute providers can also improve clinical outcomes by setting shared goals, establishing a discharge date and plan, and understanding the level of rehabilitation patients need.  We will explore how data transparency with post-acute partners provides hospital care teams clinical line of sight to ensure patients are managed effectively in place, breaking the cycle of rehospitalization.

Learning Objectives

  • Discover how live data transparency informs and facilitates effective care coordination and discharge planning between acute and post-acute providers
  • Explain how leveraging post-acute analytics to risk stratify and prioritize patients enhances collaborative care and reduces rehospitalization risk
  • Develop strategies to implement data-driven standardized care pathways to reduce variability in care

Speaker:

  • Phyllis Wojtusik, RN, Executive Vice President, Real Time Medical Systems

This session will be presented at the 2022 Ohio Hospital Association (OHA) Annual Meeting & Education Summit. 

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