GMC one of six hospitals to adopt care transitions program

LAWRENCEVILLE -- Gwinnett Medical Center's Lawrenceville campus is one of six metro area hospitals that has implemented a new transition program through Medicare and the Atlanta Regional Commission, aimed at reducing patient readmissions.

Under the program, Medicare patients who are admitted with congestive heart failure, heart attack or pneumonia will be referred to the ARC, which will assign a "coach" to follow patients for 30 days after discharge. Coaches will provide a bedside consultation with patients, followed by a home visit that will cover "medication management, the importance of follow-up visits with physicians, red flags or warnings and how to keep a personal health record."

Any need for support services will be assessed. Weekly phone calls will also be included.

"Sadly, the lack of medical follow-up and coordination of care in the home contributes to unnecessarily high national readmission rates," said Dr. Alan Bier, GMC's chief medical officer and executive vice president. "GMC's medical staff realizes that the success of any patient's outcome is based on many factors, including the quality of care provided in the hospital setting as well as the care received after discharge."

Gwinnett Medical Center-Lawrenceville will join five other Atlanta-area hospitals in the Care Transitions Program: Emory University Hospital Midtown, Piedmont Hospital, Southern Regional Medical Center, WellStar Cobb and WellStar Kennestone.

The goal, according to the ARC, is lowering hospital readmission rates by preventing problems after patients leave the hospital, thereby saving the health system money. Medicare estimates that avoidable readmissions cost the system $12 billion nationally each year.

ARC's agreement with Medicare will run for two years, with the option to extend. The organization expects to see about 4,000 patients per year.

"While the initial program includes only three diagnoses and six hospitals," a news release said, "ARC anticipates the program will add other hospitals and diagnoses as the benefits of the program are demonstrated."