I am excited about a new initiative that CCMH is participating in called the Wyoming Rural Care Transition program. The program is free for patients, as it is funded by a grant, the
Health Care Innovation Award through the
Wyoming Institute of Population Health.
The goal is to reduce the rate of readmission to the hospital for patients over the age of 65 who are hospitalized for certain diseases or conditions, and help guide those patients as they move across multiple healthcare settings.
Medicare has made the determination that if these patients return to the hospital within 30 days of discharge, CCMH will not be paid for their care. Consequently, it is in the best interest of the patients to maintain the course of outpatient treatment appropriate for their diagnosis, and it is financially beneficial to CCMH as well.
A Care Transition Nurse will meet with the patient in the hospital and begin teaching them about their condition and then follow-up with them after discharge with home and phone visits for up to 90 days. The Care Transition Nurse encourages patients to take the lead in their healthcare, teaches them how to communicate with their care providers and stresses the importance of following up with their primary care providers.
If you want to learn more about the Care Transition Program, call Angela Roesler, RN, at 307.688.1371.