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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...
Autores principales: | , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
MDPI
2021
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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. |
format | Online Article Text |
id | pubmed-7838791 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | MDPI |
record_format | MEDLINE/PubMed |
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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