ACH Expands Patient Services: Introducing Segue, Our New Transitional Care Program
The hospitalist specialty emerged more than 20 years ago and has since gained recognition as an integral part of a successful healthcare system. Hospitalists – skilled internal medicine providers who specialize in the care and treatment of hospitalized patients – bring both medical and cost efficiencies to patient care models. Patients who receive care under a dedicated hospitalist during their admission experience vastly improved outcomes and fewer readmissions than patients who remain under the care of their internists.
Advanced Care Hospitalists (ACH) is a Lakeland-based hospitalist group providing comprehensive patient care in community hospitals and medical facilities across Central Florida. As part of our commitment to continuously improving our services and leading with compassion, we’re proud to be at the forefront of a new program: The Segue Transitional Care Program.
The Segue program is directly integrated with our hospitalist services. Under this system, we’re able to provide continued care to patients in the post-acute setting. Along with medical care, Segue includes ministry outreach to help meet our patients’ emotional, mental and spiritual needs after a traumatic illness. Keep reading to learn more about our innovative, comprehensive approach.
Hospitalist Care Improves Patient Outcomes
The hospitalist specialty arose from the need to fill gaps in medical care for hospitalized patients. As the healthcare industry focus continues to shift from volume to value, hospital administrators are now recognizing the benefits of integrating skilled hospitalists into the hospital system.
Because they’re on-site around-the-clock, skilled providers are available to make more rounds and examinations, schedule the appropriate consultations, obtain and interpret test results faster, and make real-time adjustments to patients’ medications and treatments as new needs arise. Hospitalists are also immediately available when an emergency happens to provide aid and order critical treatments.
The result of more personalized care, face-to-face interactions and efficient processes is that hospitalists can reduce patients’ length of stay by up to 30% and cut hospital costs by up to 20%. On average, patients under the care of hospitalists are admitted for a shorter period, experience greater patient satisfaction and have fewer readmissions.
As patient care needs continue to evolve, ACH is building off the hospitalist program to expand patient services beyond discharge. Our integrated system ensures that patients don’t experience a disruption of necessary care during the critical 30-day period following a hospitalization.
Patient Needs Don’t End When They Leave the Hospital
Segue is a transitional care program that facilitates continued care and services for patients discharging from the hospital into a nursing home, post-acute facility, or home. The transitional period is a critical time for newly released patients, both medically and mentally. Accurate medication reconciliation and the proper transfer of discharge orders are essential to ensure patients get the care they need. Additionally, many patients undergo significant mental and emotional distress during an illness and recovery period. Failing to provide adequate physical, mental and emotional support post-discharge increases the risk of hospital readmissions and results in higher care costs.
At Advanced Care Hospitalists, our comprehensive approach to providing in-patient and post-acute care has resulted in more accurate medication reconciliation and fewer medical errors, better compliance with post-discharge treatment plans, increased patient satisfaction and fewer hospital readmissions. All these results can lower healthcare costs by thousands of dollars per case.
We offer a unique, integrated system to deliver high-quality care and treatment to post-acute patients. Our program model includes several factors that set it apart from similar programs:
- Employed care coordinators. We maintain an employed care coordinator in each partner facility. Our dedicated care coordinators personally interact with patients and introduce them to the transitional program. They call patients within 24 hours after discharge to ensure they are safely home or in their post-acute facility. Once a successful discharge is confirmed, our care coordinators schedule patients for a visit from their provider.
- Continuity of care. As part of the transitional program, patients receive a visit at home or in a nursing facility from a licensed provider. During the home visit, our providers perform medication reconciliation and a detailed review of the discharge plan and treatment orders. This ensures that our patients are set to receive the appropriate care and treatment. It reduces the risk of errors and future complications and allows patients and family members to ask questions or voice concerns.
- Ministry outreach and support. Our Segue Ministry Team works closely with every patient to identify their needs and offer support and services. Dedicated team members provide verbal support and encouragement, prayer, counseling, meal assistance, medical supply assistance, personal care needs, and home needs to eliminate barriers that impede improving and healing after a hospitalization.
Healing is a complex, dynamic process with physical, emotional and spiritual dimensions. At Advanced Care Hospitalists, we are just as committed to the ministry and outreach aspect of our transitional care program as we are to the medical aspect. Our patients require a supportive, nurturing environment to thrive while recovering from a traumatic illness or disease. The Segue Ministry Team ensures that patients have access to the physical services and spiritual fulfillment they need to focus on getting better after an illness.
The Segue program is available to all facility partners at no cost. All operations and ministry needs are funded through the clinical visits provided to patients and billed to their insurance.
Contact Advanced Care Hospitalists to Learn More
If you are interested in learning more about our programs, services, providers or becoming a partner facility, please call us at 863-816-5884 or fill out a contact form online.
