News | Published August 9, 2013

Innovative summit seeks to improve care transitions

“Providing the right care, at the right time, in the right setting”—a simple but compelling theme that brought nearly seventy representatives from various non-acute care facilities to Mount Nittany Medical Center on July 31.

These individuals gathered for Mount Nittany Health’s first “Care Transitions Summit,” a unique forum meant to foster dialogue and create plans for improving coordination of care for patients as they transition across different care settings, from primary care offices to skilled nursing facilities.

“Delivering high-quality, patient-centered care requires crucial contributions from every part of the care continuum, including and especially those involved in transitioning patients among different care settings,” said Gail A. Miller, RN, MS, CPHQ, vice president for quality.

According to Jacqueline Hahn, director of case management, inpatient nurse administrative coordinator and presenter at the summit, a key area for improvement is reducing avoidable hospital readmissions, especially within thirty days of discharge.  

“Approximately 20 percent of all Medicare beneficiaries are discharged from hospitals to a skilled nursing facility, and nearly one-fourth of those patients are readmitted within thirty days,” says Hahn. “On the whole, these readmissions are costly, frequent – and avoidable.”

To address these and other issues, summit attendees participated in facilitated discussions, sharing key challenges as well as best practices and opportunities for improving care transitions. The group cited improved patient education, clearer communications (among patients, families, nurses and providers) and streamlining processes/paperwork as the major areas for improvement.

“We each have the responsibility to reduce unnecessary errors and redundancies across the continuity of patient care,” said Miller. “Sparking a dialogue with all the key players in this arena is an important first step in the process.”

Indeed, the July 31 summit was just the beginning of in important discussion Mount Nittany Health will continue in the future. “We plan to invite our attendees back to the Medical Center to keep the conversation going,” Miller added. “As partners in patient care, we look forward to sharing quality improvement projects, tools, and resources to establish best practices in providing the right care, at the right time, in the right setting.”