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65% Drop in Readmissions for Clients Discharged from Augustana Care Chapel View with Transitions Program

  • Jun 3, 2016
  • Meaghan Puglisi
  • 4-min Read

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Partnership Earns Lifespark Tim Tucker Spirit of Collaboration Award from Augustana Care

The spirit of collaboration between Augustana Care and Lifespark began back in 2014 when they joined forces to create the Thrive On @ Home program to address a staggering statistic many people over 65 were facing after being discharged from the hospital. According to the New England Journal of Medicine, one in five people were rehospitalized within 30 days after discharge and one in three after 90 days. Today the Medicare national average for readmissions within 30 days has dropped to 15.2%. Why are so many people still returning so quickly to the hospital after going home? Many reasons are likely the culprit but at the top of the list are follow-through with discharge plans, medication management issues, support system changes once home, and early warning signs that exacerbate into emergencies.
Lyn Lais, RN, Life Care Navigator and administrator of theThrive On @ Home program has been in the health care industry for over 25 years and has seen how easily these readmissions can happen. “Despite more focus on the transition home, there are still many gaps in other programs. For example,we know that 90% of health outcomes are shaped byfactors other than health care, yet often aren’t addressed. Once people are home it can be hard to adjust and they can very easily slip into a spiral of health care crises, ultimately returning to the hospital. There’s no professionalthere using a whole person approach to help guide them through this next phase and give them the confidence and tools they need to successfully transition home.”RC swoosh icon_6.28.16

The goal of the Thrive On @ Home program is to bridge the care received at Augustana
Care’s Chapel View with care at home to improve outcomes and client experiences. Since October2015, Lyn has enrolled 140people into the Thrive On @ Home program, with 110 identified as being at high or moderate risk for readmission. Based on the Medicare national average for readmissions within 30 days, 17 wer
e likely to be readmitted. However, through the Thrive On @ Home program and Lyn’s interventions, only 6 were readmitted – a 65% drop in expected readmissions.

Additionally those that did need to go back to the hospital were able to return without the added expense or time involved in emergency room visits or ambulance transfers. These initial results are self-reported and show upwards of 65% reduction but they’ve also give us the confidence to invest in sophisticated tracking systems to analyze results going forward.

After an initial discovery during their stay at Augustana Care Chapel View, Thrive On @ Home members identified as being at high or moderate risk for readmission receive ongoing follow-up by Lyn as they return home. Lyn devises a unique plan with her team, modifying it as needed, to help members succeed after discharge using a combination of home visits, interventions, and coaching calls. “The most important thing I do is follow up with people face-to-face once they are home, to make sure any issues that could affect readmission are immediately addressed,” added Lyn. “I provide ongoing guidance, review medications to ensure they’re being taken correctly, help with paperwork, transportation, even loneliness, and connect them with reliable resources to make their plan come to life. We know people face life challenges beyond health issues so we make sure to address every element of wellbeing in our whole person approach.”
“It’s an integrated solution that stops the roller coaster of crises,” said Joel Theisen, RN, CEO/Founder of Lifespark. “Isolation is fatal – we need partners working together as systems of excellence for a continuum approach, not silos, with a whole person focus to really help people be successful once home and eliminate any gaps that often occur.”

It’s this partnership and vision that has earned Lifespark the Tim Tucker Spirit of Collaboration award from Augustana Care. “The Thrive On @ Home program is about giving people the tools they need to avoid rehospitalization after a hospital stay and short-term rehabilitation at an Augustana Care community. We can’t do it alone but together we can make sure our clients not only remain at home but thrive on,” said Tim Middendorf, Chief Operating Officer for Augustana Care. Joel added, “We’re honored to be recognized in this way. We believe in building partners-for-life and it has been a tremendous partnership with Augustana Care right from the start.”

For more information about the Thrive On @ Home program, call 877-345-3319.
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