Care Transitions Program.
It is clearly established that hospital readmissions contribute significantly to the health care costs of the Medicare program. The most vulnerable members affected by this problem are our Special Needs Plan (SNP) members. CMS requires that all SNP Plans have a Care Transition Program in place.
’s Care Transition Program has been developed to meet all CMS requirements and deliver high quality care to our SNP members during transition of care episodes. A care transition is defined as any time a member moves from one care setting to another. Anytime a member is admitted from home to the hospital, or discharged from the hospital to the Skilled Nursing Facility and eventually back home they are experiencing a care transition.
’s Care Transition Team is comprised of Case Managers, Social Workers, Pharmacists, Physicians and Care Transition Coordinators. This team will work closely with the member and/or caregivers to assist them through each and every care transition concurrently. Every time a care transition occurs, the PCP will be notified in writing. Once the member transitions to their home, the Care Transition Specialist (CTS), who is a nurse will call the member and performs a comprehensive hospital discharge assessment and medication reconciliation. The CTS will also assist the member with making an appointment to see the PCP and or any specialists needed. Copies of both the Hospital Discharge Assessment and a Medication Reconciliation Form will be mailed to the PCP.
We are confident that this program will be successful in lowering our readmission rates and improving the quality of care our SNP members receive.
The following forms are made available to the members in both English and Spanish.
- How To Prepare For Your Hospital Admission
Mailed to member prior to planned hospital admission
- Discharge Preparation Checklist
Mailed to member prior to planned admission or faxed to hospital for unplanned admission
- Medication Reconciliation Form
Mailed to member and PCP after member returns home