This portion of our program is led by the Cheyenne Regional Medical Center Aging Services Department. The Wyoming Rural Care Transition Program helps patients aged 65 and older (who have chronic, complex health conditions) to transition between healthcare settings, while helping them to build the knowledge and skills necessary to manage their conditions.

How does it work?

  1. This transition assistance begins at the time of a patient’s discharge planning, while he or she is still at the hospital. A Care Transition Nurse meets with the patient and family to begin planning hospital discharge and care transition procedures.
  2. Prior to discharge, nurses help patients to create a Personal Health Record (PHR), and offer discharge education that is specific to a patient’s diagnosis.
  3. During transition from the hospital into other settings (home, a skilled nursing facility, or transitional care unit), a nurse facilitates medication management as well as coordinating care, preparing any important information that will need to be shared at the next point of care, and helps to establish collaboration between the care providers at different locations.
  4. A nurse will educate patients about necessary skills for self-care and tips for navigating the medical system. Additionally, he or she will schedule follow-up visits for patients with their providers.

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What are the benefits?

  • Better Health—Proactive, individualized care empowers patients with the tools and knowledge necessary to improve and maintain health and quality of life, while maintaining control over current health conditions.
  • Better Care—Improving the transition of care, coordination of care, follow-up, communication, and education, leads to increased safety and improved clinical outcomes.
  • Lower Cost—Facilitating smooth transitions between hospitals and other care facilities reduces avoidable hospital re-admissions and the overall cost of care.

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How does it Help?

  • Improving Follow-Up—Half of Medicare patients do not follow up with their Primary Care Provider within 30 days of discharge.
  • Changing Outcomes—One in five Medicare patients is re-hospitalized within 30 days of being discharged.
  • Reducing Costs—Unplanned and unnecessary re-hospitalizations cost Medicare over $17 billion each year.
  • Managing Complexity—Patients who require hospitalization for serious illness or injury have a particular need for continuity between sites of care.
  • Implementing Home Visits—Nurse practitioner or nurse home visits following discharge increased patient knowledge, increased patient satisfaction, and decreased re-hospitalization.
  • Educating Patients—Patient education and coaching provided by nurses demonstrates increased patient knowledge, increased self-management behavior, increased quality of life, decreased illness exacerbations, decreased re-hospitalization, and decreased cost.

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Establishing a ‘Medical Neighborhood’

A well-functioning medical neighborhood allows for the effective flow of information across care facilities, and between clinicians and patients. The focus is centered around patients, with a balance between evidence-based care and patient preferences.

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The Wyoming Rural Care Transition Program supports medical neighborhoods by providing education and assisting in the strategy and practice behind the continuity of medical care—helping to pave the way for complex patients to transition between hospitals and other sites of care, including patient centered medical homes (PCMHs).