Catching patients on the rebound A new program at GHS is helping high-risk patients avoid readmissions after a hospital stay. By Robin Halcomb
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hile working as an inpatient case manager for Greenville Health System, Tami Woodrum, RN, often saw the need for a way to help ease the transition of patients from hospital stays back to their homes and primary care providers. GHS wasn’t alone. Hospitals across the nation face the daily challenge of ensuring patients return home successfully from an inpatient stay. The National Institutes of Health reports roughly 20 percent of recently discharged, older patients are readmitted within 30 days of discharge. The Care Coordination Institute (CCI), a GHS affiliate that centers on anticipating medical needs through data analysis, recognized a problem in need of a solution while reviewing health care data tracked from a provider network in which GHS participates.
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Leaders of CCI began meeting with GHS representatives in late 2015 to discuss their findings and consider how they might address the issue. Together, they set the goal of creating a program focused on reducing readmissions for patients who are at high risk for being readmitted or needing emergency department services. GHS’ Transitional Care Program (TCP), the first of its kind in the state, launched in December 2017. TCP, which has served more than 180 participants to date, closely follows patients during the critical month after a hospital discharge, when they are most at risk for readmissions. Misuse of medications and hospital-related complications often play a role in early readmissions. “The idea of transitional care programs is becoming more popular nationwide,” noted Thad Tuten, MD, GHS hospitalist
