Format: Audio

MP3 Download $15
Compact Disc $20

Kecia Christensen, Kathy Steffensmeier

Effective care transitions are critical to the patient experience, yet they can be difficult to successfully orchestrate. In this session, presenters will describe how Faith Regional Health Services (FRHS) evaluated the roles of case management and social work in discharge planning and then adjusted them to improve care transitions. Role changes included the introduction of a readmission risk screen via the EHR on all new admits, entering plan-of-care interventions, conducting a discharge time-out and placing post-discharge phone calls within 48 hours of the high-risk patient?s transition home. The session will conclude by showcasing the impact of these changes on HCAHPS data.