The Duke Endowment’s care transitions initiative is in an early phase, but project leaders say they’re already seeing hospitals implement best practices through the program.
Early insights include:
- Designing the care transitions program with input from a broad and diverse group of stakeholders from both Carolinas was critical. The group included representatives from the state hospital associations, public and private payers, health care providers, the North Carolina Alliance for Effective Care Transitions (NC ACT), and South Carolina Preventing Avoidable Readmissions Together (SC PART).
- Ongoing data collection is essential to tracking progress and implementing continuous quality improvement. Information gathered through a shared data portal will help track compliance with evidence-based standards.
- A series of measures have been identified. They include increased use of standardized assessment of patients’ risk for readmission; more patients receive appropriate transition services tailored to their level of risk; increased patient confidence; and improved health of patients discharged from hospitals.
- Technical assistance teams, formed through the North Carolina and South Carolina hospital associations, are providing collaborative learning opportunities, coaching calls and site visits to each hospital.
- In addition to quantitative data, a survey will help assess each hospital’s efforts toward improving community engagement and developing partnerships.