FEATURE
THE BIGGER PICTURE: How a New Norton Health Care Program is Connecting Patients from Hospital to Home
Aaron Burch
Visit the physicians, nurses and staff of any health care facility, and you’ ll find masters of their domain. These are caring public servants who together know the ins and outs, the nooks and crannies of their fast-paced environment. Harder to know is the environment beyond one’ s own facility; what happens to the patient after they leave your care?
If an at-risk patient leaves the hospital, goes to rehab, and then home, but aren’ t sufficiently cared for … what’ s to stop them from being back in the hospital months later? The disconnect that patients feel as they’ re lost in the shuffle manifests itself in unfortunate ways. One of the most notable is designated simply Return To Hospital( RTH), a recurring situation far too common among the elderly and infirm.
The good news is that health care is changing every day, and the timeline curves towards more positive outcomes. The Affordable Care Act( ACA) prompted overhauls in health care systems across the country, including many right here in our own back yard.
Dr. Carmel Person, medical director of Norton Geriatrics and several subacute rehabilitation centers, explained how changes from the ACA have prompted a closer examination of medical systems which had been left alone for decades.
“ Health care reform meant hospital reimbursement was soon reflected by patient outcomes, how much the provider and the hospital setting took ownership of the patient. This changed the dynamic of how health care organizations prioritized. It had a lot of people talking about continuity of care,” she said.“ If we can service the patient in the hospital, the patient in rehab and the patient at home, it makes sense to connect the dots.”
Dr. Person, with support from numerous partners and colleagues, began to brainstorm a structured way to provide continuity of care for the patients most likely to return to the hospital.
“ It was 2014 when I started at Norton,” said Julie Lauder, Regional Practice Manager.“ I started working more and more with Dr. Person. We realized that the hospitals are sending all these patients to rehab, and we have Norton doctors in the rehab facilities. Why aren’ t we working together? We said,‘ Let’ s turn a program providing continuity of care into reality.’”
That reality is here, and is known as the Transitions in Care Continuum( TICC). In just a few years since its inception, the emergent program has blossomed into a viable strategy for patients
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