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Transition Care Team

Transition Care Team

Excessive avoidable readmission rates have forced Medicare to implement the readmissions reduction program due to a reported spending rate of $17.8 billion a year on readmissions that could have been avoided. A fragmented health care system and lack of communication has left discharged patients confused about follow-up care, medications, and financial resources leading to unnecessary hospital readmissions and deterioration of their disease processes. Hospitals are actively seeking ways to reduce readmissions in order to not only avoid penalties, but improve patient care.

Recently, the Transition Care Team at Covenant Health Plainview – a team of front line nurses -developed a program to address the hospital’s readmission rate. Patients with conditions that often lead to hospital readmission were asked to be a part of the transition care program, at no charge. Upon discharge from the hospital, these patients were visited at home/care facility by their nursing team (the same nurses the patients see on the floor) for the sole purpose of education and encouraging follow-up with their physician. During these follow-ups, nurses educate further on the disease process, medications, and resources available for their long-term health and recovery.

Covenant Health Plainview has seen outstanding results with this program and was selected by Premier, Inc. to present this program at the upcoming Annual Breakthroughs Conference in Washington, DC. “Our front line staff are passionate, highly-skilled, forward-thinkers and are excited to be on the forefront of patient care nation-wide. This speaks volumes for the care that we provide here at Covenant Health Plainview,” said Leslie Hackett, CNO, Covenant Health Plainview.

Premier, Inc. (Nasdaq: PINC) is a healthcare performance improvement alliance of approximately 3,600 U.S. hospitals and 120,000 other providers whose mission is simple: To improve the health of communities. As an industry leader, the Premier alliance has created one of the most comprehensive databases of actionable data, best practices and cost reduction strategies. Named one of the World’s Most Ethical Companies ( 8 years in a row, Premier is well-equipped to transform the future of healthcare.

To learn more about this program and Covenant Health Plainview, please visit

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