Staff Contact: Stephen Njenga
This week is Healthcare Quality Week, a dedicated time to acknowledge the progress made by health care and quality professionals toward improving patient outcomes, and to prepare for the many challenges and opportunities that lie ahead. Recently, Harrison County Community Hospital located in Bethany, Mo., received national recognition for an innovative approach to post-acute care.
The National Rural Health Resource Center and the Missouri Office of Rural Health and Primary Care recognized HCCH for their interdisciplinary transitions of care team to improve the discharge process; enhance communication between patients, health care providers, and other caregivers; and to reduce the likelihood of readmission within 30 days.
HCCH established an interdisciplinary transitions of care team in April 2019, which included the care coordinator, nursing staff, ancillary departments, home health, primary care clinics and physicians, and a local pharmacy. The team provides education to overcome barriers before discharge and provide post-discharge, patient-specific follow-up care at various intervals based on a risk-adjusted assessment performed upon admission. Safety continues upon discharge by conducting post-discharge care visits to every patient to identify and prevent any potential risk factors for rehospitalization.
Aligning with the Triple Aim element of population health, the program addresses all patients who are discharged regardless of admission type or payer source in a holistic, integrated and coordinated manner. Through this approach, the hospital’s goal is to reduce or eliminate the need for a 30-day inpatient rehospitalization and to keep the patient in his or her own environment of care for treatment rather than in the hospital setting.