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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