Charlotte, N.C.-based Atrium Health has seen significant improvements in readmission rates since implementing a new population health model, among other strategic initiatives, the hospital told Becker's via email.
As part of its efforts to reduce readmissions, Atrium Health launched a population health model called Transition Services in 2015. The model offers recently discharged patients access to an entire care team either at Atrium Health's transition clinic or in their own homes. The care team includes physicians, pharmacists, care manager nurses and social workers who are available to patients in the month after a discharge.
Atrium Health also relies on physician-led work groups, committees and its data analytics department to collaboratively identify the causes of unplanned readmissions and implement targeted interventions.
Since implementing these strategic initiatives, the health system has seen a 4 to 6 percent reduction in readmissions annually. Patients participating in Transition Services also demonstrated a 35 percent reduction in readmission rates compared to those receiving typical post-discharge care.
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