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El Camino Hospital Implementing Enhanced Transitional Care Program

Last Updated 3/7/2013 12:56:36 PM


-Pilot program received $500,000 grant to reduce readmissions-


Mountain View, CA - March 7, 2013 - El Camino Hospital announced today that it is implementing Care Transitions, a program created to identify elderly patients who, at discharge, may be at high risk for hospital readmission and implement a comprehensive and coordinated care plan to help reduce that risk. The pilot program was awarded a $500,000 grant from the Gordon and Betty Moore Foundation, an organization dedicated to advancing environmental conservation, scientific research, and patient care, around the world and in the San Francisco Bay Area.

"Hospitals across the country, like ours, are working hard to prevent their unnecessary readmissions not only to meet changing healthcare mandates, but to ensure that our patients are receiving the highest quality and safest care," said Cheryl Reinking, RN, MS, vice chief clinical operations. "We believe Care Transitions has the potential to move the needle in preventing unnecessary readmissions and we look forward to sharing the outcomes."

The Care Transitions program builds upon another successful pilot program completed last year, which involved post-discharge care coordination with skilled nursing facilities. A multidisciplinary team of physicians, case managers, social workers and nurses, created and implemented, a proprietary risk assessment tool that first identified patients who were at high risk for readmission, and then developed a comprehensive care plan, which was shared with the facility. Extensive follow up with facility staff ensured adherence to the plan.

This enhanced transitional program will build upon these elements to also include comprehensive discharge planning and post-care coordination with not only skilled nursing facilities, but home care or other outpatient sites, as well as an educational program for patients and their caregivers, where appropriate.

A focal point of the program is the intensive medication management program. Medication reconciliation, the process of reviewing a patient’s complete medication regimen at the time of transition from one care setting to another, is an important way to prevent adverse drug events, and is a fundamental element of high quality transitional care. Studies have shown that medication counseling and reconciliation by a pharmacist as part of the transitional care team reduces recurrent emergency room visits and hospitalizations.

Care Transitions involves a pharmacy technician who, as part of this multi-disciplinary team, conducts medication reconciliation with all high-risk patients and their caregivers at admission and discharge. The pharmacists will also provide additional, intensive medication management education for patients who are at high risk of experiencing an adverse event from medications. Patients will receive a follow-up phone call within five days of discharge to reconcile medications again, and uncover any issues with medication management, or ability to obtain medications.

The hospital’s goals are to reduce readmissions at El Camino Hospital for high risk patients, leading to a 30% reduction in 30-day all cause readmission rates and a 15% reduction in 90-day all cause readmission rates compared to a 2010 baseline, and achieve sustained reduced readmission rates through at least 2016. Results of the program are scheduled to be reported this year.


About El Camino Hospital
El Camino Hospital is an acute-care, 443-bed, nonprofit and locally governed organization with campuses in Mountain View and Los Gatos, Calif. In addition to state-of-the-art emergency departments, key medical specialties include neuroscience, heart and vascular, cancer care, urology, orthopedic and spine, genomic medicine, and the only Women's Hospital in Northern California. The hospital is recognized as a national leader in the use of health information technology and wireless communications, and has been awarded the Gold Seal of Approval from The Joint Commission as a Primary Stroke Center as well as back-to-back ANCC Magnet Recognitions for Nursing Care.

About the Gordon and Betty Moore Foundation
The Gordon and Betty Moore Foundation, established in 2000, seeks to advance environmental conservation, scientific research, and patient care. The goal of the Foundation’s Patient Care Program is to create, in collaboration with others, a fundamentally better healthcare approach that improves quality and safety, reduces costs and ensures dignity and respect to both patients and those who serve them. For more information, please visit www.moore.org.

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