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Hospital Transition Program Reduces Readmissions By 53 Percent

Because patients aren’t properly educated before leaving the hospital, nor well-monitored back at home, many end up returning to the hospital for help. This model transition program prepares

The US has an 18 percent rate of hospital readmissions within 30 days of discharge and an alarming 76 percent of these are preventable, according to the Center for Technology and Aging. A program in North Carolina has successfully reduced hospital readmissions of participants by 53 percent. By addressing the complex needs of discharged patients, the “Hospital to Home” program ensures a strong, home-based recovery. A partnership between Right at Home In-Home Care and Assistance and Forsyth Medical Center, the program is the first of its kind in North Carolina and is recognized statewide as a model initiative. A patient navigator works with the patient and discharge planners to develop personalized options for support services through Right at Home, transportation to pharmacy visits and follow-up physician’s appointments, medication reminders, light homemaking and meal preparation.

"Finding and receiving adequate follow-up care after a hospitalization is a challenge thousands of aging adults face every day. Patients encounter many obstacles while transitioning from a hospital stay to becoming independent again in their homes where arrangements are often made for family and friends’ caregiving support,” said Allen Hager, chief executive officer and chairman of Right at Home. "We know the ability for patients to recover in their own homes has many benefits, from financial to emotional." 



Program Details and Results


The Hospital to Home program, primarily funded by The Duke Endowment, is currently available for patients who meet the following criteria:

  • Age 65 years or older
  • Medicare or Medicaid eligible
  • Resident of Forsyth County, North Carolina
  • Discharged to home
  • Has two or more conditions from a list of qualifications



A Hospital to Home Navigator identifies and works closely with the patients and their loved ones who are willing to participate in the program. After patients are discharged from a hospital stay, they are assisted in the home by Right at Home caregivers who can provide them with medication pick-up and reminders, transportation to follow-up physician appointments and household duties to keep their homes safe and clean. Caregivers also serve as the eyes and ears for family members and other loved ones to alert either doctors or family members if any notable situations arise. 
The program has seen high satisfaction rates with participating patients and their loved ones. The average response for overall satisfaction with the program was 4.9 on a 5-point Likert scale, with 5 being very satisfied. Additionally, 100 percent of respondents were satisfied with the Right at Home services given. Right at Home is in the process of launching a care transitions program offered to its more than 200 local, independent franchises for implementation with hospitals across the U.S. The program will strive to provide the best patient care possible while improving care transitions across the care continuum. "As the face of healthcare is changing, there will only be increased attention to this problem of avoidable readmissions and the potential savings that could be amassed by reducing them," Hager said. "We are striving to make the care transition process simpler for aging adults and their loved ones."

Implications From Preventable Readmissions On Hospitals


This type of program has potential for growth due to new provisions in the recent healthcare bill requiring hospitals to improve the quality of care for their patients or face consequences from government reimbursement sources. Preventable hospital readmissions currently cost the healthcare system $25 billion annually, according to PricewaterhouseCoopers’ Health Research Institute. In 2012, Medicare plans to eliminate payments to hospitals for preventable readmissions due to heart failure or pneumonia. The Department of Health and Human Services (HHS) will also publish each hospital’s readmission track record, beginning in 2012. As a result, programs such as Hospital to Home are growing in popularity due to their success in reducing readmissions and costs to Medicare.
 "As the number of elderly in our community increases there is an urgent need to provide care and assistance after a hospital stay," said Crystal Redding, director of case management at Forsyth Medical Center. "When elderly patients do not have the support networks necessary to help with their recovery following an illness or injury, they are at a higher risk for hospitalization. This program is helping our older residents to maintain their independence by providing individualized care during their recovery period by improving their quality of life and reducing the need for readmission to the hospital."

About Right at Home


Founded in 1995, Right at Home offers in-home companion and personal care and assistance to seniors and disabled adults who want to continue to live independently. Right at Home directly employs all caregiving staff, each of whom are thoroughly screened, trained, bonded and insured prior to entering a client’s home. All ongoing care is monitored and supervised by more than 200 local independent franchisees. Right at Home’s global office is based in Omaha, Nebraska, with franchise offices located in 40 states nationwide, the UK and Brazil. For more information on Right at Home, visit About Right at Home at www.rightathome.net/about-us or read the Right at Home caregiving blog at www.rightathome.net/blog. 



About Forsyth Medical Center


Forsyth Medical Center is part of Novant Health, a not-for-profit integrated group of 12 hospitals and a medical group consisting of 1,102 physicians in 349 clinic locations, caring for patients and communities in North Carolina, Virginia and South Carolina.


About The Duke Endowment


The Duke Endowment, in Charlotte, NC, seeks to fulfill the legacy of James B. Duke by enriching lives and communities in the Carolinas through higher education, health care, rural churches and children’s services. Since its inception in 1924, the Endowment has awarded nearly $2.7 billion in grants.