Breaking the Rehospitalization Cycle
ICS's dedicated Transition Team is focused on preventing unnecessary hospitalizations and breaking the rehospitalization cycle seen in some patients by identifying and addressing root causes. Already, we're seeing success.
“We had a member with congestive heart failure who was hospitalized six times in six months,” says ICS Director of Transitions of Care Stephanie Reynolds. ICS field nurse Ruby Rodriguez, a member of our Transition Team, went to the member’s home to help her get a handle on why she kept cycling in and out of the hospital.
“Ruby discovered that this member didn’t know she was supposed to be avoiding salt and that she could check her own weight,” Stephanie said. “Ruby got her a scale. She went over all of the teaching materials about her condition. After being hospitalized so frequently, just having someone take a little time and sit down and educate her, all of a sudden she’s like, ‘Ok, yeah! I got it!’” The member’s streak of hospitalizations was finally over. Read more about the ICS Transitions Team and what we're learning about preventing unnecessary hospitalization here.