2023 Together - PH341 - Our Eyes Are on You After Discharge: Innovative Care Transitions
The hospital-to-home transition marks an abrupt shift from provider-driven care to self-managed care, which often leads to readmissions for patients uncertain how to manage their health conditions. Our program proactively addresses this gap. A behavioral health social worker provides brief interventions for hospitalized patients and enrolls them in postdischarge home visits. During the visits, an aide in the patient’s home environment uses telemedicine to connect the patient to the psychiatry nurse practitioner. This program reduced 30-day index readmissions for patients receiving a home visit and 30-day index readmissions for patients receiving an inpatient intervention.
Target Audience
- Healthcare Quality Professionals
- Nurses
- Pharmacists
- Pharmacy Technicians
- Physicians
- Other Healthcare Professionals
Learning Objectives
Explain how utilizing a combination of screening tools can identify at-risk patients for proactive intervention.
Discuss how post-discharge telemedicine home visits help reduce unnecessary readmissions.
Heather Chung, RN, MSN, PhD, NE-BC, System Director, Psychiatric Services, Houston Methodist Hospital, Houston, Texas
Stacy Campos, MBA, Program Director, Houston Methodist Hospital, Houston, Texas
Hailey Stein, LCSW, Project Manager, Houston Methodist Hospital, Houston, Texas
Credit Types
Interprofessional Continuing Education (IPCE)
This activity was planned by, and for, the healthcare team, and learners will receive .50 Interprofessional Continuing Education (IPCE) credits for learning and change.
Available Credit
- 0.50 ACPE Pharmacist
- 0.50 ACPE Pharmacy Technician
- 0.50 AMA PRA Category 1 Credit™
- 0.50 ANCC
- 0.50 CPHQ – Certified Professional Healthcare Quality
- 0.50 General CE - Attendance
- 0.50 Interprofessional Continuing Education (IPCE)