Reducing Hospital Readmissions

California Hospital Medical Center Foundation

California Hospital Medical CenterCalifornia Community Foundation awarded a two year grant of $750,000 to California Hospital Medical Center (CHMC) Foundation to support the Coordinated Care Initiative at CHMC. The ultimate goal of this pilot project, a partnership with three local Federally Qualified Health Centers (FQHC), is to enhance care coordination across the local health care continuum in order to improve patient outcomes and reduce hospital readmissions. 

The project will utilize a health information exchange, HIE*Lite, to identify hospitalized patients who reside in the Centinela Valley and suffer from chronic diseases such as diabetes, hypertension, and/or congestive heart failure. A patient navigator will make bedside visits within 24 hours of admission and assist them in transitioning to outpatient care, including scheduling appointments to one of the partnering clinics, unless they have a different medical home, within 72 hours of discharge. Each of the clinics will provide timely and comprehensive follow-up medical care including an individualized chronic disease treatment plan, case management, assistance with medication adherence, referrals to healthy activities including nutrition, fitness, and chronic health education classes, many of which are offered by CHMC’s Community Benefits Program.