24-219 Ensure Effective Post-Discharge Care and Minimize Readmissions

Date: 03/05/24

Proactively arrange patient follow-ups within seven days post-hospitalization

Patients transitioning from hospital to home require careful follow up to prevent readmissions. Recognizing this critical phase, we have developed a proactive Transitional Care Services (TCS) program. Our goal is straightforward:

• Minimize hospital return rates: Early follow up reduces the likelihood of readmission for patients with acute conditions.
• Strengthen care coordination: We improve dialog between a patient's primary care physician (PCP) and their ongoing care strategy team, ensuring a seamless transition.
• Boost patient contentment: Involving patients in their care process enhances their satisfaction and health outcomes.

TCS program strategy: bridging the gap in post-discharge care

Our TCS initiative is designed to aid in the transitional period immediately after hospital discharge, focusing on critical post-discharge follow-up appointments. Under our TCS program's strategy:

• We reach out to providers promptly to verify that each patient's post-discharge services and follow-up meetings are organized—or have been conducted—within seven days after leaving the hospital.
• Through this concerted effort, we anticipate a decline in patient readmissions, enriched conversations between patients and physicians, and consequently, higher patient satisfaction rates.

The involvement of all parties in post-discharge planning is essential for a patient's recovery cycle. Our TCS program embodies this commitment to collaborative care, leading to healthier outcomes and happier patients.

Additional information

If you would like to refer members to our TCS program, please call 866-801-6294. This line is not for authorization related questions. If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral health providers can call 844-966-0298.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Imperial county.