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Health Team

Program aims to help reduce hospital re-admissions among older patients

Posted May 23

— Older patients with high-risk injuries or illnesses often don't make a smooth transition from hospital to home. Now, different providers are working together to reduce hospital re-admissions.

Last March, 84-year-old Ellen Richardson fell in a parking lot and broke her hip.

After surgery and recovery at Duke Raleigh Hospital, she spent more than three weeks at Hillside Nursing and Rehabilitation in Wake Forest.

Home care workers made sure she was safe and steady at home.

"It was just a great experience for me," she said.

However, often failures in communication between hospitals, primary care doctors, nursing homes and home care services increase the risk of the need for emergency care or a hospital re-admission.

That can cost nearly $10,000 per patient.

The North Carolina Hospital Association and its counterpart in Virginia set up the Hospital Engagement Network to simplify communication and cooperation between hospitals, nursing homes and home care services.

"We are working as a team to get the patient to the right place at the right time to meet their needs," said Karen Preston with Duke Raleigh Hospital.

Since 2011, across North Carolina and Virginia, the program has prevented more than 3,500 re-admissions a year and $43 million in projected costs.

The same initiative is also focused on reducing hospital-acquired infections.

While Richardson was still in the nursing home, a doctor there ordered a CT scan that revealed clots in her lungs. The nursing home sent that information with her back to Duke Raleigh Hospital.

"That was another good thing, because they didn't have to repeat that scan, and they could treat me right away, which they did," Richardson said.

It was the right kind of hospital readmission – for a new medical problem, not one that was missed because of gaps in the system.

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