The Healthier Washington plan has been designed by leaders in our state to transform health care by ensuring that health care focuses on the whole person, improving how we pay for services, and building healthier communities through a broad collaborative regional approach. Consistent Care Services in partnership with the Greater Columbia Accountable Community of Health has been awarded State Innovation Model funds to develop the community-based Readmission Avoidance Pilot in Benton and Franklin county. This program utilizes nurse case managers and student nurses to provide discharge planning, home visits, and care coordination for patients identified as being at risk for readmission.
The Readmission Avoidance Program seeks to decrease Medicare 30-day unplanned all-cause readmissions. This project uses Registered Nurses (RN) and Medical Assistant Community Health Workers (CHW) to provide case management and care coordination at discharge for Medicare patients at high risk for readmission. The patient’s medical and social needs will be addressed with intensive case management through connecting the patient with local community and medical resources. This program can be designed to target readmissions in two different ways; it can target all readmissions from Medicare beneficiaries, or it can target 30-day unplanned all-cause readmissions for Medicare beneficiaries with applicable conditions (heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and coronary artery bypass graft surgery). The second group being the penalty group for many hospitals.