The Healthcare Association of New York State recently recognized Cortland Regional in its NYS Innovation Spotlight
for its strategic efforts to reduce readmissions for patients with congestive
heart failure (CHF) and chronic obstructive pulmonary disease within 30
days of their discharge.
Patients are vulnerable when being transitioned from one care setting to
another. The Transitional Care Program at
Cortland Regional Medical Center addresses potential risks associated with patient transitions by using
concepts and tools from well-known programs, such as the Care Transitions
Intervention ™ and Project RED (Re-Engineered Discharge).
A Registered Nurse Transitions Coach facilitates interdisciplinary collaboration
and care continuity and encourages patients and caregivers to participate
in care plan execution. The coach also partners with staff from a nearby
cardiology office that provides early interventions to prevent emergency
department visits and potential admission. Home healthcare nurses visit
patients at home within 72 hours after discharge to answer questions and
assist with future appointments.
More than 460 patients have been offered participation in the program;
86% of those accepted. Over the course of one year, 30-day hospital readmissions
for CHF patients decreased to 14.3%. The 30-day readmission rate for the
CHF patients in the program was reduced from 50% to 12%.