Hospitalization Reduction

Hospitalization Reduction Program

Seniors are prone to hospital readmissions. Nearly one quarter of all Medicare patients return to the hospital within one month of discharge. The good news is that many of those admissions are considered preventable.  


Top 10 Ways We Reduce Hospitalizations and Readmissions

  1. Timely Initiation of Care – We open within 48 hours of referral.  
  2. Informed Plans of Care – We work to obtain discharge summaries and instructions.  
  3. Medication Management / Physician Medication Reconciliation 
  4. Identify Frequent Flyers – We provide extra attention, monitoring and oversight for those with multiple hospitalizations.
  5. Identify High-Risk Patients – We examine readmission patterns to determine which patients, with which conditions, diseases or procedures, have the most readmissions.  
  6. Call the Nurse First Program – To prevent unnecessary visits to the ER and hospital. 
  7. Fall Prevention Program – Utilize fall risk assessment tool and home safety evaluations.  
  8. Private Duty Transitional Care Program – Packaged pricing for intermittent care to 24/7 care.
  9. Home Safety & Telehealth – To better manage chronic diseases and comorbidities.  
  10. Patient Engagement / Ownership in Recovery Process – Encourage participation through active listening, clear communication, education, teach-back strategies and the opportunity to plan for wellness.