The Centers for Medicare and Medicaid (CMS) have adjusted assessment criteria that results in a person needing to be very ill to be eligible for admission to a hospital. Hospital pharmacy staff utilize interventions at the inpatient level to reduce the length of hospital stay. A patient comes in sicker and leaves earlier.
The question is no longer "if" the discharged patient needs (cause they all do) follow up care, but rather how do hospital staff connect the person to the right community provider. The 2013 hospital staff mantra is we communicate with local resources.
Wisconsin's PATH ALONG is a successful model of a collaborative organization. The PATH ALONG model represents a longer term strategic investment on an integrated approach between hospital departments and community providers to coordinate care.
PATH ALONG is an original Wisconsin model that connects inpatient providers to community staff who support the patient during health system transitions. PATH ALONG is evidence based with scheduled review that inserts findings in to policy and guideline update meetings. Staff accompany the person on the inpatient stay with ongoing discussion aimed at encouraging participation in appropriate follow up care.
The PATH ALONG model has three defined services to help the hospitalist fulfull their continuity of care role. The focus is on care filled transitons.
Check out the site below with free access for more information
http://www.homecarepath.com/Pages/PRESSRELEASEOriginalWisconsinModelToReduceHospitalReadmissionRates.aspx
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