The Delta Care Transitions program is a community-based project designed to improve health outcomes for at-risk, rural patients who transition from in-patient to out-patient settings. The goal is to reduce hospital readmissions, and thus cost, for patients with chronic illnesses who have a history of multiple hospitalizations.
Developed in partnership with South Sunflower County Hospital, Indianola Family Medical Group, and Leland Medical Clinic, the program assigns specially trained patient navigators to ensure that individuals receive appropriate post-discharge follow-up care, patient education, assistance navigating health care programs, and access to support services for family caregivers. In this way, patients seek follow up care from local clinics and physicians, rather than from hospitals. Two objectives are realized: patients receive care that is typically more personal and more timely while reducing the overall cost to the health care system.
South Sunflower’s biannual survey specifically commended the program for reducing the hospital’s readmission rate from 2014 to 2016. For the last year, the project has focused on patients with diabetes, chronic lung disease, pneumonia, and chronic heart disease. Of the 160 participants in the program, none were readmitted within 30 days of diagnosis.