FEATURE
readmissions. To that end, the Transitional
Care Team used a risk-stratification software tool that helped predict whether a
patient would be readmitted. Patients were
classified as low-, medium- or high-risk
based on their likelihood of readmission.
“With this information, we were able to
provide patients appropriate resources
based on their risk,” Mae said. Low-risk
patients were given an 800 number to call
if they had questions about their care. The
results of those questions were visible to the
Transitional Care Team. When necessary,
these patients would receive additional
interventions.
Medium-risk patients received the 800
number, plus phone calls from a nurse on
the third, seventh and 21st days after discharge. High-risk patients received the
medium-risk interventions, plus an
in-home visit by a nurse practitioner 30
days after their discharge.
“We served more than 1,500 patients and
reduced readmission rates by almost half,”
Mae said. “If patients were readmitted,
their expenses were lower, and we reduced
mortality rates. Because of the pilot’s success, we are expanding this model to other
hospitals within our system.”
Mae said this latest grant is inspiring
because it builds on previous experience
and allows Baylor to pilot a program that
could improve patients’ lives outside the
walls of the hospital setting. “If we’re successful, we will provide better care for our
“If we’re successful, we will provide better care for our
patients and improve patient outcomes at a lower cost.”
– Mae Centeno,
Vice President, Chronic Care Continuum
patients and improve patient outcomes at a
lower cost. And if we can do this, we’re
impacting not just patients within our system but potentially patients and health care
systems around the country.”
Philanthropic funding is still needed to expand
this initiative and provide innovative care teams
to additional Baylor-affiliated primary care practices. For more information on how you can support this or other community health initiatives at
Baylor, contact Cynthia Krause at 214.820.7928
or [email protected].
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