Published on February 19, 2014

Holzer Hosts Lunch and Learn Session

Holzer held a Lunch and Learn session focused on Transitional Care Education. Transitional Care is the seamless transition of care for the patient from the Hospital to the Post-Acute Care setting. This includes coordinating a safe transition of patient to the post-acute care setting, reducing readmission rates for our patients, enhancing patient satisfaction, coordinating services, etc. to increase the patient experience for the communities we serve.

“Customers are driving the shift from short-term acute care to long-term chronic care services, covering all stages of life,” presented Teresa Remy-Detty, Vice President of Post-Acute Care Services, Holzer Health System. “The care process is moving from provider-dictated service to provider-counseled for patient ownership of self-management of health. The Center of Medicare Services (CMS) directive focuses on management of high risk and high cost patients and reducing those healthcare costs. Reducing re-admission rates, utilizing family practitioners and reducing emergency department visits, and lowering adverse outcomes are a few of the ways those individuals can be transitioned to better care management. Over the next 16 years, the number of people in the United States that will be 85 years old or older will double to 8.5 million. Establishing transitional care will reduce the amount of healthcare costs accumulated by these individuals.”

Also showcased at the luncheon was the Community Care Transitions Program through the Area Agency on Aging District 7. Connie Montgomery, Director of Aging and Disability Resource Center, commented “The Care Transitions Program Goals are to reduce hospital readmissions and reduce long term nursing facility placements.”

Through the Care Transitions Intervention program, patients are support by a Transitions Coach and learn self-management skills to ensure their needs are met during the transition from hospital to home, using the Coleman Model. The Coleman model consists of pillars: Patient Health Record, Medication Reconciliation, Red Flags, Primary Care Physician Follow-Up, and Community-Based Care.

Holzer is planning another Community Network Lunch and Learn Session for Monday, April 28 at the Holzer-Gallipolis facility. Registration is at 10am with the program to begin at 10:30am to 2pm. Lunch will be provided. All clinical and administrative staff from skilled nursing, assisted living centers, and home health providers are encouraged to attend. Please register by April 14 at (740) 446-5165 or email info@holzer.org.

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