Care transitions are the process that people go through as they move from one care setting—such as a hospital or acute care facility—to another setting, such as the person’s home. Over the course of an illness, a person may experience multiple care transitions. Coordinating care across these transitions is a vital step in reducing preventable hospital readmissions.
A workgroup composed of representatives from the Primary Care Coalition (PCC), Montgomery County Department of Health and Human Services, Housing Opportunities Commission, local hospitals, community residents, and 20 other organizations and individuals from the community is working to implement post-discharge protocols to improve care transitions and prevent hospital re-admission. The group adopted the name “HEALTH Partners” (Hospitals Effectively Assisting Lasting Transition to Home).
HEALTH Partners meets monthly, convened by the PCC, and tests different strategies to improve outcomes. Current tests in progress include: Medication Therapy Management, Nursing Wellness Programs, eHealth Literacy Platform, EMS activity notification, and Discharge coordination between hospitals and resident counselors.
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