In collaboration with a statewide transitional care program, Beaufort Memorial Hospital has been able to significantly reduce readmission of Medicare patients treated for acute myocardial infarction. The number of heart attack patients having to return for treatment within 30 days of discharge dropped 20 percent between 2014 and 2015, earning BMH recognition at a meeting in Columbia for participants of the program called Preventing Avoidable Readmissions Together (PART).

Established in 2012 by the South Carolina Hospital Association, BlueCross BlueShield of South Carolina, Health Sciences South Carolina and The Carolinas Center for Medical Excellence, PART provides educational resources to hospitals across the state, along with opportunities to share experiences, innovations and best practices.

“Partnering together and connecting into the larger community is an innovative and effective approach that has proven successful,” said Lorri Gibbons, vice president for quality and patient safety at the South Carolina Hospital Association. “The PART program plays an important role in our overall goal to provide safe, high quality care for every patient.”

At BMH, at-risk patients transitioning from the hospital to home are monitored by a team of two health care professionals to ensure they are following their plan of care. Working in collaboration with physicians and specialists, the practitioners are able to intervene quickly; adjusting medication as needed should the patient’s health status change. Known as Bridge to Home, the hospital’s transitional care program originally targeted chronically ill patients with congestive heart failure, chronic obstructive pulmonary disease (COPD) and pneumonia. This summer, BMH received a $287,000 grant from the South Carolina Hospital Research &amp; Education Foundation to expanded Bridge to Home to include all Medicare patients at high and moderate risk of readmission.

Part of the funding is being used to develop a classification system that will help health care providers identify patients likely to be readmitted to the hospital based on their ability to care for themselves. Those at high risk will receive a follow-up phone call within 24 hours of discharge, a home visit by a health care professional within three days of discharge and a follow-up visit to their primary care provider or specialist within seven days of discharge. Moderate risk patients will receive a variation of the prescribed monitoring.