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The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly

Background: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with contin...

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Autores principales: Powers, James S., Abraham, Lovely, Parker, Ralph, Azubike, Nkechi, Habermann, Ralf
Formato: Online Artículo Texto
Lenguaje:English
Publicado: MDPI 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838791/
https://www.ncbi.nlm.nih.gov/pubmed/33418873
http://dx.doi.org/10.3390/geriatrics6010004
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author Powers, James S.
Abraham, Lovely
Parker, Ralph
Azubike, Nkechi
Habermann, Ralf
author_facet Powers, James S.
Abraham, Lovely
Parker, Ralph
Azubike, Nkechi
Habermann, Ralf
author_sort Powers, James S.
collection PubMed
description Background: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions. Methods: This is a quality improvement report, the geriatric patient-aligned care team (GeriPACT) at Tennessee Valley Healthcare System (TVHS) participated in ongoing quality improvement (Plan, Do, Study, Act (PDSA)) cycles during teamlet meetings. Post home discharge follow-up for GeriPACT patients was provided by proactive telehealth communication by the Registered Nurse (RN) care manager and nurse practitioner. Periodic operations data obtained from the Data and Statistical Services (DSS) coordinator informed the PDSA cycles and teamlet meetings. Results: at baseline (July 2018–June 2019) the 30-day all-cause readmission for GeriPACT was 21%. From July to December 2019, 30-day all-cause readmissions were 13%. From January to June 2020, 30-day all-cause readmissions were 15%. Conclusion: PDSA cycles with sharing of operations data during GeriPACT teamlet meetings and fostering a shared responsibility for managing high-risk patients contributes to improved outcomes in 30-day all-cause readmissions.
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spelling pubmed-78387912021-01-28 The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly Powers, James S. Abraham, Lovely Parker, Ralph Azubike, Nkechi Habermann, Ralf Geriatrics (Basel) Communication Background: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions. Methods: This is a quality improvement report, the geriatric patient-aligned care team (GeriPACT) at Tennessee Valley Healthcare System (TVHS) participated in ongoing quality improvement (Plan, Do, Study, Act (PDSA)) cycles during teamlet meetings. Post home discharge follow-up for GeriPACT patients was provided by proactive telehealth communication by the Registered Nurse (RN) care manager and nurse practitioner. Periodic operations data obtained from the Data and Statistical Services (DSS) coordinator informed the PDSA cycles and teamlet meetings. Results: at baseline (July 2018–June 2019) the 30-day all-cause readmission for GeriPACT was 21%. From July to December 2019, 30-day all-cause readmissions were 13%. From January to June 2020, 30-day all-cause readmissions were 15%. Conclusion: PDSA cycles with sharing of operations data during GeriPACT teamlet meetings and fostering a shared responsibility for managing high-risk patients contributes to improved outcomes in 30-day all-cause readmissions. MDPI 2021-01-06 /pmc/articles/PMC7838791/ /pubmed/33418873 http://dx.doi.org/10.3390/geriatrics6010004 Text en © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
spellingShingle Communication
Powers, James S.
Abraham, Lovely
Parker, Ralph
Azubike, Nkechi
Habermann, Ralf
The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly
title The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly
title_full The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly
title_fullStr The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly
title_full_unstemmed The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly
title_short The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly
title_sort geripact initiative to prevent all-cause 30-day readmission in high risk elderly
topic Communication
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838791/
https://www.ncbi.nlm.nih.gov/pubmed/33418873
http://dx.doi.org/10.3390/geriatrics6010004
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