Community Foundation supports transitions of care

The Fairfield County Community Foundation announced an award of $16,000 to the Southwestern CT Agency on Aging to support a root cause analysis to identify the reasons why so many individuals are readmitted to area hospitals within 30 days of discharge.

The Center for Medicare and Medicaid Services (CMS) has studied the incidence of hospital readmissions and estimates that $12 billion of the $15 billion spent on hospital readmissions is avoidable. Registered Nurses will review the charts of discharged patients to identify the hospital-based systems and community-based challenges that lead to preventable readmissions for Medicare beneficiaries.

Working with St. Vincent’s Medical Center, Norwalk, Stamford and Danbury Hospitals, the Southwestern CT Agency on Aging is developing an application to the Center for Medicare and Medicaid Services to embed patient education, medication reconciliation and personal health records into the discharge process.

A transition of care takes place every time a patient moves from one healthcare setting to another. The transition is often marked by a change in setting, as in hospital to home. Care transition danger points are plagued by communication discrepancies, medication inconsistencies, lack of primary care follow-up and hospital readmission. These break downs and errors can be frustrating, expensive and pose significant risk for the patient.

Dr. Pam Hoffman, a geriatric physician at St. Vincent’s Medical Center and a member of the Southwestern CT Agency on Aging Board said, “Our older patients should be able to move seamlessly from home to hospital to nursing home to home care. Failure to communicate accurately the patient’s full diagnosis list, complete medication regimen including all changes in medications, and the plan of care from the moment of discharge all too often results in adverse events, sometimes necessitating readmission to hospital. We seek systems to improve communication at all interfaces in the continuing care spectrum.”

The Fairfield County Community Foundation promotes the growth of community and regional philanthropy to improve the quality of life throughout Fairfield County. Individuals, families, corporations and organizations can establish charitable funds and contribute to existing funds. The Foundation provides philanthropic advisory services, and develops and leads initiatives to tackle critical community issues. It is in compliance with the Council on Foundations’ national standards for community foundations. The Foundation has awarded over $151 million in grants to nonprofits in Fairfield County and beyond.

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The Southwestern Connecticut Area Agency on Aging is a nonprofit organization whose mission is to promote dignity and independence of older adults and persons with disabilities. For more information or assistance navigating the challenges of aging, call SWCAA at 800-994-9422.


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