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Building a Community-based Continuum of Care to Support Patients

As we transition patients from the inpatient setting at Lawrence General Hospital to the post-acute setting, we are moving from just a patient hand-off to closer collaboration for more efficient, high-quality care. On February 12th, representatives from 11 different community providers of skilled nursing, rehabilitation and home health and hospice care, came together at Lawrence General to talk about the care of shared patients. 

Robin Hynds, RN, senior director of care integration and transformation, shared information about our current risk-sharing environment and our collaborative work with patients in the CMS Pioneer Accountable Care Organization. She presented our population health goals for shared patients as the catalyst for better alignment and communication among providers in all settings. The meeting was well attended and participants provided great feedback and shared ideas for moving forward toward shared goals, understanding that this is not an easy task. Watch for more news on this collaboration in future newsletters.

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