Did you know: According to a MEDPac assessment*, 18% of Medicare patients admitted to the hospital result in a hospital readmission within a 30-day period - costing the government $15 billion dollars annually. The appropriate transition of care from hospital to home can prevent many of these readmissions.

That’s why Alegis Care launched our Transition of Care Program in 2019 with the Texas Valley Organized Physicians (VOP) Independent Physician Association (IPA) and 30 of their primary care providers (PCPs) in the Harlingen, Texas region. The program connects an Alegis Care clinician with patients upon discharge to help them transition their care from the hospital or other care facility to their home.

Here’s a story that demonstrates how this program can help our providers deliver better health outcomes and more affordable care for the patients they serve by helping prevent hospital readmissions.

Teresa, an Alegis Care RN, is dedicated to the Transition of Care Program. When a participating patient is being discharged from the hospital to their home, Teresa receives a notice of a scheduled time for an in-person evaluation with the patient in their home.

Teresa visited a patient who had been discharged to her home after a hospital admission for chronic obstructive pulmonary disease (COPD) and congestive heart failure with shortness of breath. Based on clinical notes, Teresa knew this patient had an elevated heart rate while in the hospital and was diagnosed with atrial fibrillation which is an irregular heartbeat. The patient was also prescribed a new medication and had the dosage of an existing medication adjusted.

While evaluating the patient during this visit, Teresa discovered the patient appeared fatigued and had a dangerously low heart rate. Teresa reviewed the patient’s medications and recognized that two of their prescribed medications can cause the heart rate to lower. Teresa’s intuition and timely assessment placed this patient at high risk for readmission. She then quickly reached out to the patient’s PCP and cardiologist to notify them of the patient’s status. The physicians agreed to discontinue the medications, and Teresa scheduled follow-up visits for the patient with both her PCP and cardiologist.

Teresa’s quick clinical intuition and assessment saved this patient from a repeat trip to the hospital.

By visiting this patient in her home so quickly after being discharged from the hospital, Teresa also:

  • Helped the patient continue her progress toward a quality health outcome
  • Saved her patient the additional cost and stress of another hospital readmission
  • Demonstrated value for two distinct customers: the provider and patient

Teresa and the Transition of Care Program team are improving the health, well-being and peace of mind of the patients they support.

*N Engl J Med. 2009 Apr 2;360(14):1418-28. doi: 10.1056/NEJMsa0803563.

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Nurse helping patient at home after a hospital stay

Valuable Insights: Reducing Readmissions

Teresa speaks about the in-home care interventions she conducts after patients have been discharged from the hospital. (17 min)

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