Humboldt County’s Care Transition Program Sees Results

21 Feb 2013

St. Joseph Hospital’s Care Transition Program, which was highlighted last week during the Robert Wood Johnson Foundation’s Care About Your Care webcast, has seen avoidable emergency department (ED) readmission rates drop since 2006. The Care Transition Program began with a goal of realizing a 20 percent decrease in readmission rates for heart failure and chronic obstructive pulmonary disease (COPD). For the year ending September 2012, it exceeded the COPD goal by chopping the readmission rate to 8.3 percent and came close to the heart failure goal with a 13.9 percent readmission rate. The 20-percent reduction is part of a larger effort throughout Humboldt County to reduce unnecessary costs in the health care system and improve the quality of care.

The Care Transition Program at St. Joseph’s Hospital in Eureka, CA, employs care transition coaches to review medication lists and provide self-management support, patient education, and other tools for discharged patients. The coaches are senior-level nursing students from Humboldt State University. Said discharged patient Joan K. of the Care Transition Program, “It made a big difference to me going home. My coach came to see me in the hospital before I was discharged, then came to my home several times over a three-week period. She made me feel safer when I went home. I knew she was always available if I had a question or concern, or needed her to explain something to me.”
St. Joseph’s Hospital partners with community organizations to expand their capacity. After 60 to 90 days, care coordination for frequent emergency room utilizers transitions from St. Joseph Care Transition to Priority Care nurse managers. Priority Care continues to support patients after an ED visit, especially those facing complex and often chronic health needs that can be managed but not cured.     
The top 50 users of the St. Joseph Emergency Department are now being studied. In 2011, the top ED users had 1,359 visits, an average of two trips per person per month. Those whose primary care provider is Eureka Community Health Center are the focal point of the multi-disciplinary attempt to address their needs and keep them out of the ED. These combined efforts will help further decease emergency room admission rates. 
Read more from the Times-Standard of Northern California here