Hospital Spotlight: Helen Newberry Joy Hospital Deploys Efforts to Improve Transitions of Care

Posted on September 06, 2018

Hospital SpotlightIn 2014, Newberry-based Helen Newberry Joy Hospital began its focus on improving transitions of care by participating in an MHA Keystone Center initiative that concentrated specifically on moving patients from one setting of care to another.

The initiative provided Helen Newberry with the opportunity to identify its target population, which is rural residents with limited access to care. Furthermore, it was discovered that, due to a provider shortage, patients were waiting up to 30 days to secure an appointment with their primary care provider. This led to a suspected increase in emergency department (ED) visits and patient complaints, as well as subsequent hospitalizations.

Helen Newberry’s overall mission was to improve patients’ access to primary care and decrease the time frame from hospital discharge to primary care follow-up to prevent unnecessary hospital readmission and/or ED visits.

To accomplish this, Helen Newberry created a transition of care process in 2016 that directs nurses to follow up with each patient within 24 hours post-discharge and the primary care office to follow up 48-72 hours after discharge. As the initiative progressed, a care coordinator was hired to track the patient from point of discharge to follow-up care.

The care coordinator completes a weekly report of all hospital discharges, reviews the LACE index (length of stay, acuity of admission, co-morbidities, and emergency room visits) for each patient, and tracks the number of primary care patients who are likely to be readmitted to the hospital or visit the ED. The care coordinator also receives a daily discharge list from the two closest regional hospitals to be aware of potential patients who could be admitted to Helen Newberry.

The hospital also hired four midlevel providers to assist with its provider shortage and allow patients to see doctors sooner. Patients can now be seen by a provider in the practice clinic within a few days  of discharge.

Additionally, if a patient is seen in the ED and does not have a primary care physician, a referral is sent to the care coordinator to assist the patient in securing one.

Helen Newberry has been transparent in its efforts with this new initiative — the care coordinator does a weekly radio show to share information with the public about the transition of care program, and monthly data is posted in the ED and shared with various hospital/clinic committees.

The focus of this project has been to carry each patient smoothly through each transition of care within each department at Helen Newberry by enhancing communication, adding staff and other resources, and improving the culture of safe care.

This article was featured in the MHA Keystone Center Newsletter. To subscribe, please contact Ashley Sandborn, MHA Keystone Center communications specialist.


  • Hospital Spotlight: Helen Newberry Joy Hospital Deploys Efforts to Improve Transitions of Care

Tags: MHA Keystone Center, emergency department, Helen Newberry Joy Hospital, transitions of care

Posted in: Patient Safety and Quality

MHA Updates Delivered to You

Subscribe to the MHA Monday Report weekly newsletter or our podcast, the MiCare Champion Cast, to keep informed about the latest healthcare news and events in Michigan.

MHA Monday Report
Contact us to subscribe

MiCare Champion Cast
iTunes | SoundCloud

Media Inquiries

Contact the MHA at
(517) 703-8601

Read the MHA policy on publication via MHA media.

MHA 100 Year Anniversary

Watch the video »