News | Published May 19, 2014 | Written by Gail Miller, RN, MS, CPHQ, vice president for quality

Care Transitions Summit brings national speaker, progress updates from work teams

On May 6, 2014, the third Care Transitions Summit was held at Mount Nittany Medical Center, once again bringing together representatives from local healthcare organizations with a shared goal of providing the right care, at the right time, in the right setting.

The summit featured a nationally recognized speaker, Eric Coleman, MD, MPH, professor of medicine and head of the division of healthcare policy and research at the university of Colorado’s Anschutz Medical Campus. Dr. Coleman kicked-off the summit with a presentation describing the challenges of improving care transitions alongside a nationally-changing healthcare policy landscape. He also discussed the effectiveness of having a care transitions coach, and elaborated on a seven-prong approach to improving quality and safety during care transitions.

After Dr. Coleman’s presentation, the teams that were formed to address each of the three focus areas identified during the first Care Transitions Summit provided updates regarding their projects.

The first team, preventing avoidable readmissions, is working to reduce avoidable 30-day readmissions across multiple areas including acute care, inpatient rehabilitation, skilled nursing, home health and hospice. Specifically at Mount Nittany Medical Center, initiatives such as social service assessments, emergency department case managers, nurse navigators and patient rounding programs are in full force to reduce avoidable readmissions within 30 days of discharge.

The second team, standardized communications among all care levels, is working to standardize forms and tools that can be shared across many areas of care. Thus far, the team has collected data and reviewed options for creating a form that can be used across the continuum. The next step is to implement a pilot program and begin to gauge effectiveness.

The third team, patient/family education and health information, is working to provide useful tools to help patients and their families manage their health. By creating a three-ring binder resource guide, the book is meant to include information such as appointment logs, personal health records, and important diagnosis-specific instructions that are understandable and user-friendly. The group will then begin to pilot their project and monitor success.

After hearing each team’s update, Dr. Coleman applauded the collaborative efforts of the Care Transitions team. “I’m blown away by your efforts. You’re leaps and bounds ahead of the country in creating a cross-continuum of care,” he said.

Dr. Coleman also identified key themes among all the presenters, which he says will help assure success. “Your projects are data-driven, include the families, recognize the importance of relationships and improve communication, which all help to keep healthcare local,” he said. “I’m so impressed.”

The first Care Transitions Summit was held in July 2013, bringing more than 70 representatives from non-acute care settings together at the Medical Center to discuss ways to improve coordination of care for patients as they transition across different care settings. The July summit was followed by a November 2013 summit to share “best practices” for care transitions.

Since the beginning, it has been a pleasure to work with so many dedicated and enthusiastic healthcare partners to improve care transitions for our patients. Everyone involved has been dedicated to safety and quality care for the patients and families we serve every day.

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