In April 2016, after recognizing the negative impacts that readmissions can have on the Quadruple Aim, Jackson Health Network, Henry Ford Allegiance Health and community partners worked together to address this critical issue. The result was the launch of Transition Coordination. This program is designed to ease the transition from hospital to community.
Regardless of a patient’s primary care provider, anyone discharged from Henry Ford Allegiance Health with one of the following diagnoses receives a call within 24 to 48 hours post discharge.
This call, among the others that are extended throughout the course of 30 days, is aims to mitigate barriers (e.g., accessing equipment and medications), reviewing discharge instructions, ensuring follow-up with primary and specialty care, and providing ongoing education to people on how to better cope with their conditions.
Over time, connections were made with the community paramedic program to provide additional intervention and avoid utilization of the Emergency Department. Transition Coordination is linked to Care Management as hand-offs can be made for patients needing assistance beyond 30 days.
Since its inception, this successful program has helped Henry Ford Allegiance Health’s readmission rates steadily decline. For example, COPD readmission rates in 2020 averaged 8.6% as opposed to the system rate of 20.8%.
Transition Coordination continues to evolve. Access to new technologies provide the ability to track people who are being discharged from facilities other than Henry Ford Allegiance Health, including skilled nursing and rehabilitation facilities, as well as other long-term and acute care hospitals. These advancements will undoubtedly contribute to successful gains through the ability to monitor patients at the Network level.