This document summarizes Right At Home's initiative to reduce preventable hospital readmissions through transitional care programs. It provides details on: - The definition of care transitions as the movement of patients between healthcare settings, and common problems like confusion, medication errors, and lack of primary care follow-up. - Hospitals facing pressure to reduce readmissions, with 1 in 5 being preventable at a cost of $25 billion per year. - Why transitional care programs can help by addressing environmental changes like financial penalties, and having been shown to save hospitals money while improving patient care. - An overview of Right At Home's program services including identifying risk factors, care coordination, communication, and post-dis

1. RightTransitionsSM
RIGHT AT HOME’S INITIATIVE
TO REDUCE HOSPITAL
READMISSIONS

2. CARE TRANSITIONS
DEFINED
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The movement patients
make between health care
practitioners and settings
Examples of problems:
 Patient confusion
 Medication errors
 Poor follow up with PCP

3. HOSPITALS UNDER PRESSURE TO
REDUCE READMISSIONS
 1 in 5 are preventable
 Most are preventable
76%
 Readmits cost $7,200 each
~$25 billion/year

4. WHY A TRANSITIONAL CARE
PROGRAM?
 Change in environment
Penalties
 Transitional programs work!
Save the hospital money
Increase the quality of care
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5. PROGRAM OVERVIEW
 Service Offerings:
Identify red flags
Coordinate care
Communicate with other care providers
Meal preparation, medication reminders and
transportation

6. FORSYTH H2H PROGRAM
 Program Outcomes*
65% reduction in readmissions
99% patient satisfaction
Cost per readmit → $7,661
Hospital savings → $1.1 million
 Right at Home Outcomes
Average hours of RAH services → 23.7
*As of November 2010
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7. FORSYTH H2H PROGRAM
Program Design:
 Patient eligibility determined (based on risk factors)
 Hospital Navigator explains program to eligible patients
 Hospital Navigator communicates plan of care to RAH
(e.g. number of hours, patient details, transportation
needs, red flags)
 Service starts; RAH assigns staff
 Weekly communication on each patient between
Navigator and RAH
Revise plan of care as needed
 Service ends
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8. FORSYTH PROGRAM UTILIZATION
 Meals/Shopping – 35%
 Transportation – 34%
 Housekeeping – 49%
 Medication
Reminder – 8%
 Other – 25%
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Meals/Shopping
Transportation
Housekeeping
Medication
Reminder
Other

9. OTHER Right At Home TRANSITIONAL
CARE PROGRAMS:
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10. NEXT STEPS
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Follow up with
additional information
Discuss date for next
meeting/call

11. RIGHT AT HOME
FOX VALLEY AND CHICAGO SW SUBURBS
KATHY WETTERS
630-780-9766
KWETTERS@RIGHTATHOMECARE.US
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