Enhancing Patient Outcomes and Reducing Readmissions

  • Location:Room 304
  • Session Number: H05
Tuesday, October 10, 2017: 1:00 PM - 2:00 PM
CPE:1.2 | AAPC: 1 Core B, CPPM | ACHE: 1| CME: 1 | CNE: 1   Click here for more info
Learning Objectives:  Basic
Learning Format:  Traditional


Catherine Hamilton BSN MS MBA
Nursing Operations Manager
Sutter Physician Services
Gina Bell MD
Senior Director, Clinical Operations
Sutter Physician Services


When high-risk patients are discharged from the hospital, how do you monitor their health, ensure they adhere to clinicians' instructions, and reduce their risk of readmission? Many recently discharged patients have questions concerning their medication, test results, follow-up care and even their bills. A well-designed Care Transitions program ensures patients obtain support from a knowledgeable, empathetic, licensed nurse who is familiar with their case. Sutter Physician Services (SPS) has developed a Care Transitions program to help bridge the gap between hospital discharge and a follow-up visit with a primary care physician. The goal of the program is to improve health outcomes and decrease readmissions by proactively reaching out to patients to provide clinical support as well as helping them overcome any social barriers to obtaining medicine or additional care. Dedicated nurses help guide patients as they adjust to post-discharge health issues and responsibilities. This presentation will examine how SPS built a successful Care Transitions program. By examining a detailed case study, attendees will learn how SPS managed to improve patient outcomes and decrease hospital readmissions for its patients.

Content Area(s)

Learning Objectives

• Discuss the components of a successful Care Transitions program
• Analyze a Care Transitions implementation case study and lessons learned
• Organize the benefits from the standpoint of clinical outcomes and financial return