By: Ryan Duey

The Clay County Medical Center (CCMC) and its five Rural Health Clinics (RHCs) have been focusing on increasing the rate of patients who are seen within seven days of hospital discharge by improving care transitions after admission to CCMC, with the use of a Transitional Care Management (TCM) team.

Julie Crimmins, Director of Inpatient Services, said they could get expertise on care transitions in conjunction with the Kansas Health Collaborative and their HQIC team members.

The TCM team at CCMC identified key steps needed to achieve success in care transitions. Crimmins discussed why it’s important to schedule a follow-up visit with your Physician after a hospital discharge.

The work of the TCM team has helped raise the follow-up appointment rate of CCMC patients by over 10% in the past six months, to a follow-up rate of over 97%. Crimmins said this project is an ongoing effort as CCMC’s goal is for 100% of discharged patients to have follow-up appointments.