Acute Team Update

AnnieDeaverBy Annie Deaver, LMSW, Acute Care Project Manager

Focusing on Improving Patient Transitions Post ED Discharge

The Acute Care team has been deeply focused this quarter on helping hospitals begin preparation for system transformation through clinical integration.

The team is presently collaborating with several hospital sites including Erie County Medical CenterNiagara Falls Memorial Medical CenterOlean General Hospital and Buffalo General Medical Center—our first Kaleida Health hospital site.   Our Acute Care milestones will be achieved through hospitals adapting a more collaborative approach to patient care, which necessarily involves linkages to appropriate levels of care post hospital discharge. We are initially focused on improving patient care transitions post discharge from emergency departments.

For the Acute Care team, the overarching aim is to assist hospitals in achieving a 25 percent reduction in avoidable emergency department and hospitals visits over the next few years. An initiative this past quarter, which lays the groundwork for hospital system transformation, is formulation of an Acute Care workgroup at Buffalo General Medical Center, this group will meet regularly, with a focus on developing best practices around workforce strategies and strategies to hard-wire practices for reengineering patient discharges.

An additional hospital-level plan enacted by the Acute Care team is the review and implementation of evidence-based protocols for reducing 30 day hospital readmissions.We are additionally helping hospitals prepare for VBP (Value-Based Payment) which will improve healthcare quality, including the quality of care provided in the inpatient hospital setting.   Lastly, ‘Lessons Learned’ sessions have been completed at three hospital sites. During these sessions, we facilitated forums with patient navigators to develop protocols and best practices for engaging patients within emergency departments.

For the upcoming quarter, we are developing an Acute Care Dashboard, which will enable our PPS to share hospital-level statistical information across hospital sites. This will assist in development of partnerships among hospitals of sharing best practices. The Acute Care team is collaborating frequently with Millennium’s Practice Transformation Specialists and area primary care providers to act as a conduit for patients in connecting more meaningfully to primary care—which is critical for system transformation.


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