The Collaborative Patient Care Pathway

The Collaborative Care Pathway™

Fact: 22.6% of Medicare patients discharged from hospitals are readmitted within 30 days for the same medical reason they were originally admitted. Furthermore, 75% of those readmissions were deemed avoidable.

Preventable readmissions have multiple causes, but patients’ and their families’ inability to “self-manage” chronic medical problems at home is the biggest underlying cause. Patients (and their caregivers) are often deficient in four domains of self-management competence: They may lack a necessary understanding of their illness, aren’t convinced that they need prescribed treatments, don’t adequately understand their medication and self-monitoring regimens and have serious deficiencies in their ability to communicate in an effective and timely fashion with their doctors and healthcare team.

Helping patients, families and hospitals, Kissito Healthcare has addressed this issue with the implementation of the Collaborative Care Pathway™. This evidence-base program, developed in Collaboration with Dr. Steven Hahn, Professor of Clinical Medicine at the Albert Einstein College of Medicine, is designed to provide chronic disease self-management education and support. This new focus on patients’ and families’ ongoing disease self-management role will help return patients armed with adequate support and essential knowledge, attitudes and skills so that they will be able to remain happy and healthy at home and not return unnecessarily to the hospital.

The Pathway addresses four domains of self-management competence during the patient’s post acute stay: Disease awareness, health care communication, treatment competence and adherence attitudes. Assessing and enhancing patient and family competence in these domains requires collaboration, coordination and partnership among patients, families, hospital caregivers and post acute healthcare teams. The benefits of the Kissito Collaborative Care Pathway will be reflected in better disease outcomes, smoother transitions of care from hospital to post-acute to home, reduced hospital readmissions and lower costs.