Housecall Providers Transition Team Working to Reduce Hospitalizations

November 6, 2013

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Please click on the picture to watch interviews with transition team members and Executive Director Terri Hobbs.

Early in Housecall Providers involvement with the national demonstration project, Independence at Home (IAH), we realized our success hinged upon transition care – and once up and running, the results have been significant. The transition team has been so successful in preventing hospital admissions and re-admissions that this fiscal year we hired two more transition nurses to support our IAH patients as well as our general population. It is the goal of the transition team, now comprised of three RNs and two social workers, to see all of our nearly 1,400 patients that visit the ER or enter the hospital (approximately 91 ER visits and 50 hospitalizations a month). In addition, our transition nurses assist our primary care providers in managing our highest risk patients to prevent the need for hospitalization.

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