Enhanced Transition of Care for Residents of Lincoln County

Project Term: 12 months; Ended 2018
Grant Amount: $44,236

This project sought to develop a new approach to discharge planning for hospitalized patients that systematically identified and addressed the social factors that influence health outcomes (such as the ability to afford home heating, food, housing, and medications). The project’s overall goal was to reduce re-admissions related to socioeconomic barriers to health, increase the acuity of patients seen in the emergency departments, and encourage better utilization of local clinics for outpatient care. A discharge planning tool was successfully developed, and staff hired to work with patients during the admission process to determine after discharge needs. During this project, Cabinet Peaks Medical Center experienced a 23% decrease on average in re-admissions. Strong community partnerships were also developed which will help address the ongoing health and social needs within the community.

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