At Home Care

Keeping Patients at Home

At Home Care
“I’m so scared that one day I just won’t wake up,” admitted the 40-year-old heart failure patient. He kept going back to the hospital because that was the only place he really felt safe.

Care providers at the Regional Medical Center in Orangeburg stepped in and found a home health agency that could monitor his blood pressure, weight and glucose levels remotely. They got him into a cardiac rehabilitation program. They helped him understand his medication instructions. They gave him peace of mind.

It was an aggressive but reachable goal: significantly reduce unnecessary re-hospitalizations so patients suffering from chronic conditions could stay home with their families and sleep in their own beds at night. How was this achieved? By bringing a large, fragmented community together to close communication gaps, form active partnerships and create new best practices.

In 2012 health care and community service organizations across South Carolina came together to tackle readmission rates in South Carolina. More than 200 diverse providers from all corners of the state brainstorm solutions, trade stories, share successes and frustrations, and give one another advice and support. It’s about building a map to smoother transitions of care – together.

Since 2012, avoidable readmissions have been reduced by 15 percent. That’s 1,400 hospital stays avoided. South Carolina now ranks 9th in the country in the improvement of readmissions. These efforts have saved patients $14 million in hospital costs and provided the opportunity to stay at home instead of reentering the hospital unnecessarily.