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DHS council urges sustained, data‑driven push to reduce avoidable hospital stays and improve complex transitions
Summary
DHS and the Acute Care Transitions Advisory Council asked the committee to support a standing, data‑driven effort to expand regional capacity and reduce avoidable hospital days for people who lack appropriate community supports.
The Department of Human Services and the Acute Care Transitions Advisory Council presented recommendations and preliminary data to the committee, urging sustained investment in regional capacity, a unified measurement system and short‑term policy changes to reduce avoidable hospital stays for people who lack appropriate community supports.
Assistant Commissioner Natasha Mers said DHS used federal funding to stand up a complex transitions team and has established three pilot regions with transition coordinators who follow people for about six months after discharge. "We have been successful in establishing kind of three regions of the state and hiring transition coordinators ... This team will also follow folks for about six months post discharge to make sure that they're not getting readmitted," Mers said.
What the data show
DHS presented preliminary referral data indicating the most common reason hospitals request assistance is the lack of appropriate…
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