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READMISSIONS: What is a transitional care bundle?

Kaiser Permanente Northwest (Portland, Ore.) developed a transitional care bundle in 2009 intended to assist patients on discharge from hospital to home.  The initial results of implementation of this approach are reported in this study.  Hospital inpatients are assigned a risk level – high, medium, or low – and then receive different level of support services.  The services include:

  • Telephone hotline number
  • Same-day standardized discharge summaries and discharge instructions
  • Post-hospital follow-up – 5 days for high risk and longer for lower risk patients
  • Medication reconciliation

In the 269-bed hospital that was studied, about half of all patients discharged from hospital to home were judged to be high risk.  In the 5 years studied, the readmission rate was cut from 12.1 percent to 10.6 percent.

Source: Rice, Y.B., and others. (2016, Feb.). Tackling 30-day, all-cause readmissions with a patient-centered transitional care bundle. Population Health Management, 19(1), 56-62.  Click here: http://online.liebertpub.com/doi/pdf/10.1089/pop.2014.0163

Related news item: Erich, J. (2015, July 1). Kaiser Permanente’s plan to prevent readmissions. IH Executive. Click here: http://www.ihexecutive.com/patient-care/clinical-pathways/article/12076292/kaiser-permanentes-plan-to-prevent-readmissions  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

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