On Tuesday Aug. 18, Sen. Mark Warner attended a round table at Riverside Regional Medical Center. The topic discussed was care transitions Intervention through the Eastern Virginia Care Transitions Partnership. The goal of this partnership is to engage the patient to participate in their care and link the patient to community based organizations. By meeting these two goals hospital readmissions have decreased.
One key component of the partnership is the use of a care transition coach. The coach begins working with the patient in the hospital and through the different transitions of care. Ada Allen, a patient who used this program said she knew what she had to do to recuperate but did not do it. However, her coach empowered her to take the necessary steps and take her life back.
Coaches are social workers who use the four pillars of care approach:
Medication self-management where the patient becomes knowledgeable about medications and has a medication management system in place
Dynamic patient-centered record so the patient understands why and how to use a Personal Health Record to improve communication with the primary care provider and specialist.
Follow up on health care schedules to complete visits with the primary care physicians and specialists
Red flags to alert the patient about indications that their condition is getting worse and how to best respond.
Sen. Warner is interested in the EVCTP as a state and potentially national solution to reduce hospitalizations.
Representatives from Riverside Health System, Bon Secours Health System, Mary Washington Healthcare, Sentara Healthcare and Area Agencies on Aging all attended the round table discussion.
Published: August 19, 2015