CATTARAUGUS COUNTY, NEW YORK – For the past 18 months, three Cattaraugus County health care organizations have been participating in a quality improvement collaborative focused on transitions of care for frail elders. The participating organizations included HomeCare & Hospice, Olean General Hospital, and The Bogoni Center. The collaborative was supported and sponsored by the Community Health Foundation of Western and Central New York.
The purpose of the collaborative was to stimulate change in practice and care delivery systems to improve transitions for frail elders as they move from one health care setting or practitioner to another as their condition and level of care needs change. This can include transitioning from a nursing home to a hospital or from home without care to home care or transitions from one physician to another.
“During transitions of care between health settings, information shared with patients and their caregivers is often confusing or missing critical information, but with better management of these transitions comes improved continuity, a reduction in error and delay and an increase in patient control of health decisions,” said Ann F. Monroe, president, Community Health Foundation of Western and Central New York.
The HomeCare & Hospice, Olean General Hospital and The Bogoni Center’s project focused on supporting the transition of congestive heart failure and chronic obstructive pulmonary disease patients from hospital to home care. The team developed self management tools to help reduce avoidable hospital and emergency room admissions. At the end of the project, only 17.5% of patients who participated were readmitted within 30 days and 10% within 60 days. Most patients also reported goals achieved and showed improved patient activation scores.
“By using these care transitions, we have helped patients reach personal goals, become better self managers and take a more active role in their own health care,” said Anna Snyder, HomeCare & Hospice and team leader.
About the Community Health Foundation of Western and Central New York: The Community Health Foundation of Western and Central New York is an independent private foundation. It invests in, and partners with, organizations and communities in innovative ways to improve health and healthcare for the vulnerable and underserved. The Foundation’s Board of Trustees has selected frail elders and children from communities of poverty as targeted populations for health improvements over the next several years. The Foundation is based in Buffalo and has a second office in Syracuse. For more information, please visit chfwcny.org.
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