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Message from Leadership: New Transition Team Will Help Reduce Readmissions

Published July 21, 2014

As People of Providence, we remain committed to our patients’ health and well-being, ensuring we provide them with the highest quality and compassionate care as we answer the call to know me, care for me and ease my way. As we continue along this journey, I want to share with you an exciting initiative that supports our endeavors of Creating Healthier Communities, Together.

To help ease our patients’ way, we are introducing a new team that will play an integral role in the patient care experience, beginning Tuesday, July 22. This team, recognized as the transition team, will have responsibilities for discharge planning, monitoring and recording patient’s needs, and assigning appropriate people to assist in patients’ transition out of the hospital. Using a color-coded system, as identified by the direct care nurse, the transition team members will coordinate the transition of care from the hospital back to the patients' primary care provider. The entire team will work together to ensure patients receive ongoing care post-discharge, as needed. Part of this follow-up will include scheduling an appointment with the patients' provider so a care plan is developed, helping to prevent hospital readmission.

All of our patients being discharged to their home will receive at least one phone call post-discharge, and many will receive contact from either the Transition Planning RN or the Care Manager at their primary care provider’s office. For patients being discharged to settings other than their home, Transition Planning MWMs and Transition Associates will be in contact with the facility to ensure transition occurred smoothly.

Patients entering the hospital for open heart surgery or total joint surgery will receive preoperative education and transition planning from the Transition Coordinators.  Each of these surgical specialties will have two Transition Coordinators accountable for their care prior to operation all the way through recovery. 

Why is this new model of care important?

The average patient at Providence Regional Medical Center interacts with more than 80 caregivers in a four-day stay. Each caregiver works to ensure successful recovery and prevent readmission. However, each interaction is also an opportunity for confusion and miscommunication. This is why Providence Regional Medical Center Everett, Providence Medical Group, The Everett Clinic and Providence Hospice and Home Care are excited to bring this new model of care to our patients.

We look forward to keeping you informed of this initiative as it unfolds. If you have any questions, please contact me directly at 425-261-4288 or Kim.Williams@providence.org