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  • Care Transitions Program

    At Kindred, improving patient experience is a key priority.

    What is the Care Transitions Program?

    The Care Transitions Program is a quality improvement program designed for patients who have complex medical conditions. The program has led to a proven track record of success with superior clinical outcomes, high patient and physician satisfaction, and quality care across multiple Kindred care settings.

    This program is designed to:

    • Reduce readmissions
    • Improve outcomes, key quality metrics and the patient’s experience
    • Increase communication and follow through with the patient’s primary care provider
    • Provide greater continuity of care to and from different care settings
    • Promote patient engagement in care planning and goal setting
    • Reduce medication errors

    The program begins when a patient is admitted to a Kindred site of care and continues throughout their stay with us and their return to the community.

    What is a Care Transitions Manager?

    • Patient advocate and navigator who communicates directly with patients, caregivers and primary care physicians or specialists every step of the way and facilitates transitions between settings helping to fill in communication gaps
    • The Care Transitions Manager does not replace any member of the care team, but rather works collaboratively with the team and serves as an additional educational resource to engage patients and caregivers and help them understand disease processes, care plans, medications and follow up care

    What will the Care Transitions Manager do?

    • Visit the patient within 72 hours of admission into the program and at least weekly thereafter
    • Visit the patient within 24 hours of each transition to ensure continuity of care protocols by providing a warm and written handoff so the receiving provider has complete information to care for the patient
    • Visit the patient at home within the first 24 hours to minimize the risk of rehospitalization during this especially vulnerable transition time
    • Partner with the patient and health care team to develop specific and aligned health goals
    • Provide educational tools and resources that will increase understanding of medical conditions and wellness
    • Provide notice to patient’s primary care physician upon admission to the program, with each transition, and completion of care with Kindred
    • Work with the patient to complete a Personal Health Record that serves as an interactive communication tool/ accurate record with the primary care physician and other healthcare providers
    • Follow up via telephone for several weeks after care has been completed

    The program is available in the Boston, Cleveland, Dallas, Indianapolis and Las Vegas markets at this time with plans to extend to many additional markets.