CEP America Reduces Readmission Rates while Optimizing Care Transitions
Sutter Delta Medical Center
|Annual ED Visits
At Sutter Delta Medical Center in Antioch, California, CEP America has demonstrated how effective transitions of care can build value across acute care settings. Driven by CEP America’s leadership and collaborative culture, the care teams at Sutter Delta have effectively created a flow of information between the emergency department (ED), urgent care centers (UCCs), and an independent skilled nursing facility (SNF) that works to deliver the necessary care to patients.
In the process, CEP America has transformed the traditional patient hand-off from a series of isolated and disjointed transitions into a systematic and comprehensive plan – a plan that harnesses patient data and equips each department to maximize their role in managing population health while providing better coordination of care across the Acute Care Continuum.
Josh Sheridan, MD, MS, Medical Director of the Sutter Delta ED and two UCCs, drew upon his leadership training with CEP America to design effective transitions not only within and between hospital departments, but also with outpatient settings such as a nearby, independent SNF. Focusing on these care transitions enables patients to receive appropriate care both before admission and after release from the hospital.
“We set out to reduce readmissions and gain efficiency by focusing on the care transitions between the ED, UCCs, and SNF," says Sheridan. “By anticipating the strategic value each department can have within our care continuum and utilizing technology to foster communication, we have been able to optimize our transitions of care and help our patients avoid readmissions.”
Looking towards the outcome measures specified by CMS, Sheridan and his team focused on tackling congestive heart failure, pneumonia and diabetes. The team makes sure that the UCCs work with the SNF to provide preventative heart care to their population; while also making sure that their patients take necessary medications and establish heart-healthy home health regimens. When patients do require ED services or hospitalization, on release they are smoothly transitioned back to post-acute care in the UCC or to the local SNFs, with follow-up on care and medication management.
Within months of implementing the care transitions program, CEP America’s providers at Sutter Delta were able to reduce readmissions to the hospital by six percent.
“Having an ED and two UCCs working closely with an independent SNF,” says Sheridan, “has enabled us to work together as one team and provide the care our patients need in multiple settings.”