GHS’s Transitional Care Program Helps to Reduce Hospital Readmissions


OXFORD, NC (April 15, 2014) - Granville Health System (GHS) reported that their Transitional Care program helped significantly reduce the rate of hospital readmissions to more than 3% below the North Carolina state average.

The Transitional Care Program is designed to provide personalized services to patients and assist them in transitioning to the next level of care. Patients transitioning from a hospital stay to skilled nursing care, medical rehabilitation, specialized medicine or primary care will work with a Transitional Care Coordinator to make this shift as seamless as possible.

The Transitional Care Program is offered at Granville Health System in partnership with the Northern Piedmont Community Care Collaborative. The group seeks to improve the health and quality of life for all North Carolinians by building and supporting better community-based health care delivery systems.

The Transitional Care Coordinator ensures hospital patients have follow-up appointments with their primary care physician, arranges for home health care services and even visits patients at home to assess their recovery.

“I am a patient’s link to numerous services offered at GHS,” says Transitional Care Coordinator Wendi Yancey. “My main goal is to put patients in touch with a primary care provider to keep them healthy and prevent hospitalizations.”

The Transitional Care Program was developed as part of the 2010 Strategic Plan and the vision of the GHS Board of Trustees and medical staff. The development of Primary Care as a service line allowed the Health System to expand the program for transition care. The concept was guided by a Council made up of Board members, staff, medical staff and community, to include the Granville Vance District Health Department.

One key aspect of Transitional Care is education for both the patient and the family. Often, the Transitional Care Coordinator’s first step is making sure the patient and the caregivers understand the discharge instructions from the provider and that the patient understands how to take the medications prescribed. Discharge instructions are the directions given to the patient by the physician outlining what steps or items the individual should continue or monitor for their ongoing recovery. These instructions typically include direction on lifestyle changes, medications, durable medical equipment, follow-up care, and signs / symptoms of concern.

Another important aspect of Transitional Care is facilitating the patient and his / her family’s ability to manage their care at home. The Transitional Care Coordinator works with the patient and their family to develop a personalized plan of care that includes strategies for healthy goals aimed at preventing future hospital admissions. For the personalized plan of care, the Transitional Care Coordinator follows up on the provider’s instructions on a level that meets the needs of the individual patient and their family.

“Although the concept of Transitional Care has recently been receiving a lot of attention, it is not a new program for Granville Health System,” said CEO L. Lee Isley. “Our system has been offering this type of specialized attention since 2012 and our rate of hospital readmissions has remained low.”

Readmission rates for January 1, 2013 through March 31, 2013 were 8.4%. This measure counts all discharges that have been readmitted to any acute care facility in North Carolina within 1 to 30 days after their initial discharge. The North Carolina state average during this period was 11.9%. The performance rate for GHS is statistically significant, being more than 3 percentage points less than the state average.

The readmission rate includes all patients, including all payers and uninsured, who are readmitted for any reason to an acute care facility within 1 to 30 days. Same day readmissions are not included. The date range is the last complete quarter reported by The Readmissions Readiness Initiative (RRI). The group provides insight into the sources of hospital readmissions in an effort to improve quality of care and reduce costs associated with preventable readmissions.

Christopher Sorrels, M.D., a provider at Granville Primary Care, Oxford, often sees patients who need help shifting from a hospital visit to primary care.

“The Transitional Care Program allows me to focus on offering my patients a continuum of patient care. We are providing comprehensive, patient-centered care for families, where patients have a medical home with their primary care provider,” said Sorrels. “This type of relationship leads to healthier outcomes for my patients and a healthier community overall.”

The Transitional Care Program also works closely with the Emergency Department at Granville Health System in the area of diabetes management. When a patient arrives in the Emergency Department with uncontrolled blood sugar levels, the Transitional Care Coordinator is notified.

“Patients who have undiagnosed diabetes are likely to visit the Emergency Department,” says Yancey. “Making an appointment with a Primary Care Provider the very next day is critical for the health of the patient. A Primary Care Provider will help educate them about their condition and help them manage their blood sugar.”

GHS was named a national leader in preventing readmissions and hospital acquired infections by the Partnership for Patients, a public-private partnership working to improve the quality, safety and affordability of health care.

In addition to the low rate of hospital readmissions, GHS has performed well in the prevention of hospital acquired conditions (HAIs). For example, in 2013 GHS reported 0 ventilator-associated pneumonia infections per 1,000 device days. The other facilities in the Duke Infection Control Outreach Network (DICON) had an average of rate of 6.1 of these types of infections in the same period.

GHS also achieved perfect scores on the following HAIs during 2013:
• Colon surgical site infections (GHS=0, DICON=2.58 per 100 procedures)
• Abdominal Hysterectomy surgical site infections (GHS=0, Coalition =0.54 per 100 procedures)

The Partnership for Patients is comprised of federal agencies, hospitals, health care organizations, patient organizations and private-public partners. The federal agencies involved include the U.S. Department of Health and Human Services and the Centers for Disease Control.

About Granville Health System
For more than 92 years, Granville Health System has been delivering quality health care close to home. To meet the growing needs of our community, Granville Health System has expanded its services throughout Granville County, offering convenient access to medical care where you work and live. GHS received a number of national awards, including the Hospital of Choice Award which named Granville Health System as one of the top 100 hospitals in the country in 2009, 2010, 2011 and 2012. GHS also received the Community Value Index Five-Star Hospital Award, placing GHS in the top 20% of hospitals in the country in offering financial value to the communities served, while reinvesting back into facilities in order to provide for current and emerging health needs. Recently, Granville Health System was named one of the nation’s Top Performers on Key Quality Measures by The Joint Commission, the leading accreditor of health care organizations in America. The GHS main campus is located at 1010 College Street, Oxford, North Carolina. For more information about Granville Health System visit GHS online at

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