Written by: Center for Care Innovations

Dr. Susan Cumming and Terry Winter, RN, describe the partnership between Marin General Hospital (MGH) and mobile based platform ZynxHealth to create the nation’s first mobile care transitions network. This webinar describes the project.

MGH targeted a patient’s entire health care experience from, admission to the hospital to their post-discharge health services. MGH simultaneously launched a three-pronged approach which included the use of Carebook (an online mobile platform for patient coordination and secure messaging), the Agency for Healthcare Research and Quality’s (AHRQs) Project Red guidelines for all patients, and a post-discharge intervention program for high-risk patients over 65.

As a result, Marin General Hospital saw:

  • 30-day readmissions for patients over 64 years old down trend to almost 8%
  • Quicker, more efficient communication and messaging (65% reduction in pages)
  • 39% of coached patients had a medication discrepancy discovered
  • Today, the new electronic coordination process is a part of the daily clinic flow. The use of the application and building of partnerships continues to expand to community health care partners in Marin County.

This webinar is hosted in partnership with the UCSF Center for Excellence in Primary Care (CEPC), with support from Blue Shield of California Foundation. This webinar is part of a series supplementing the Facilitating Care Integration resource center, which offers strategies, tools and best practices for integrating primary care with various domains of the medical neighborhood.

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