VHAN Key Aim
Transitions of Care
Our vision is to reduce preventable readmissions by creating collaborative transitions of care processes to increase team-based support for at-risk and high-risk patients post-discharge.
What VHAN Is Doing
Three-phase Interaction Action Plan
VHAN created an action plan to reduce the readmissions rate by 2% and improve transitions of care. Using patient-level data analysis, the plan identifies readmissions trends and opportunities to refocus or implement new interventions. It also places an enhanced focus on medication management, improved patient follow-up, and coordination of care across settings and providers. Data-driven approaches are targeted at improving workflows, exploring home-based care models, and increasing advanced care planning and palliative care initiatives.
Identification of Readmission Trends and High ED Utilization
Using 2019 as baseline, we found that readmission rates at seven large VHAN practices were higher than VHAN’s median readmission rate. Clinical Quality Transformation Advisors completed a transitions of care assessment with each practice, and then shared engagement strategies for preventing readmissions.
Those strategies included:
Developing Action Plans
to identify patients and reasons for readmission
Leveraging Best Practices
to help improve rates at lower-performing practices
on readmission rates and clinical categories for readmissions
Publishing Monthly ED Reports
to help pinpoint outreach for education and care management opportunities
All focus practices had a decrease in readmission rates for their Medicare population, and
three focus practices had a decrease in their readmission rates for the commercial population.
The True Value
Robert is 77 years old and was recently hospitalized due to shortness of breath and lower extremity edema.
He has a history of high blood pressure and high cholesterol.
After Robert was discharged from the hospital, a VHAN RN followed up and
learned that Robert needed extra support.