Pike County Memorial Hospital is a licensed acute care facility. The hospital provides extensive inpatient and outpatient services that include the latest technologies in radiology, laboratory testing, surgery, physical therapy and much more. The hospitals clinics include services in allergy, cardiology, orthopedics, podiatry, pulmonology, gynecology and pain management.
Pike County Effective Care Transitions Purpose:
To improve care transitions for chronic disease patients to improve quality, health status and costs.
Target Patient Population:
The service area for the project is Pike County and surrounding area. The target population is individuals who lack a primary care provider who seek care at Pike County Memorial Hospital’s emergency department for one of the following: diabetes, cardiovascular disease, high blood pressure or depression, and individuals who have a history of smoking or tobacco use and/or weigh outside normal parameters.
Quality Improvement Model(s):
To address the needs of the target patient population, Pike County Effective Care Transitions (ECT) will utilize several models to improve quality of care and patient health outcomes, including: Primary Care Health Home, Chronic Care Model and the Institute for Health Improvement Model in conjunction with evidence-based care transition practices. While there are multiple models being utilized, the models will work together to address specific components of care and patient management to achieve the most effective results.
Pike County Memorial Hospital proposes to implement ECT to improve the quality and safety of health care. Through ECT, care transitions from the hospital emergency department and inpatient settings to other settings will be improved, thereby reducing hospital readmissions and inappropriate emergency department utilizations. ECT will also focus on improving coordination of care and establishing a primary care health home for chronic care patients without an identified primary care provider.
As a result of ECT, Pike County Memorial Hospital expects to demonstrate quality and performance improvement in the delivery of care to chronic care patients through improved clinical outcomes and reduced total cost of care for the target population.