Clarion Hospital recognized for new program

From staff reports

Clarion Hospital was recognized by the Hospital & Healthsystem Association of Pennsylvania for implementing a care coordination program to address the needs of patients experiencing chronic health conditions, such as COPD, pneumonia, congestive heart failure and diabetes, and individuals determined to be at higher risk of hospital readmission.

Patients with chronic health conditions are often at high risk of re-hospitalization, so Clarion Hospital started a program in 2021 to assign a care transition navigator to work with patients upon discharge.

The care navigator may assist patients by scheduling follow-up appointments, coordinating transportation or providing community resources to individuals needing food, and disability, housing or energy assistance. The care navigator contacts patients one week after being discharged from the hospital, then again at 30, 60, and 90 days to check in and provide additional support as needed.

Since its inception, rates of hospital readmission of patients experiencing chronic health conditions have gradually declined, along with the total cost of care. The care coordinators have assisted 415 patients since the program was implemented and have expanded their resources to include the newly added Food Institute and Lifestyle Coaching programs located at the Health & Wellness Center.