|NEWBURGH, IN – The Heart Hospital at Deaconess Gateway was recently awarded by Health Care Excel for its participation in the Centers for Medicare and Medicaid Services (CMS) Care Transitions project. The Care Transitions project focused on improving patient coordination across the continuum of care.
Utilizing the Coleman Transitions Model, the Heart Hospital and USI School of Nursing students developed a collaborative program that focused on reducing congestive heart failure patient readmissions to the hospital within thirty days of discharge. During the project, patients discharged from The Heart Hospital received a personal health record to take with them to all physician appointments, and instructions on medications. The personal health record includes the patient history, medications and appointments. In addition, patients had follow-ups from USI nursing and social work students, and were tracked for impact on readmissions. The student nurses were assigned to patients seven and fourteen days after discharge to inquire about their health, to see if the individual patient has kept his or her doctor’s appointments and to ask about any questions the patient might have had.
The Heart Hospital service area was one of the fourteen communities nation-wide chosen to participate in the Care Transitions project by CMS. The project was spear-headed by Rebecca Englert, quality/regulatory specialist for The Heart Hospital; Sally Finley, case manager at Deaconess Hospital; and Jane Swartz, faculty at USI.
Health Care Excel is a nonprofit health care consulting company established in 1974 for the purpose of providing clinically based, objective, and independent monitoring of the quality, appropriateness, and medical necessity of health care services. The company is located in Terre Haute, Indiana.