The Institute for Healthcare Improvement's Triple Aim is to improve care, improve health and decrease cost. A difficult problems in healthcare is the frequency of 30-day readmission to the hospital. Often the cause for readmission are related to medication problems and to poor care transitions. SETMA has designed a care transition program which combines the forces of a hospital care team with informatics and care coordination to: A. Provide a hospital plan of care to patients upon admission B. Complete a Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan at discharge which includes a reconciled medication list, an assessment of risk of re-hospitalization, and follow-up appointments within 2-5 days. C. A Care Coaching call the day after discharged from SETMA's Department of Care Coordination SETMA's program has led to a 20% decrease in re-hospitalizations and a 37.4% decrease in cost of care for Medicare beneficiaries.
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