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Care Transitions, Rehabilitation, and Readmission Reduction

presented by Jason Falvey and Kyle Ridgeway

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Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Accreditation Check:
Ideal care transition models and programs lack rehabilitation professionals. This course will connect current best practices for care transitions to specific recommendations for how rehabilitation professionals can integrate into currently designed programs. Optimal rehabilitation management will be covered, spanning both acute and post-acute care.

Meet Your Instructors

Jason Falvey, PT, DPT, GCS, PhD

Jason Falvey is a post-doctoral fellow at Yale University. His research training focuses on disability and recovery for older adults after acute hospitalization, and how physical function contributes to hospital readmission risk. He received his PhD in Rehabilitation Science from the University of Colorado, Anschutz Medical Campus in 2018. He previously received a dual BS…

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Kyle Ridgeway, PT, DPT, CCS

Kyle J. Ridgeway, PT, DPT, CCS, is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy (CCS). He received his Bachelor of Arts degree in Neuroscience from Pomona College in Claremont, CA and his Doctorate of Physical Therapy (DPT) degree from the University of Colorado, Anschutz Medical Campus. Currently, he is a physical therapy…

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Chapters & Learning Objectives

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1. Ideal Care Transitions

This chapter gives an overview of ideal care transition models and how rehabilitation professionals can interface with current processes.

2. Optimal Rehabilitation Management of Care Transitions: Acute Care

This chapter describes the optimal approach to acute care therapist management of and contribution to care transitions.

3. Optimal Rehabilitation Management of Care Transitions: Post-Acute Care

This chapter explains the optimal approach to post-acute care therapist management of and contribution to care transitions.

4. Q&A

This Q&A session is a roundtable discussion with Jason Falvey, PT, DPT, GCS, PhD about his experience as a physical therapist.

More Courses in this Series

Overview of Hospital Readmission Reduction Programs: Relevance to Rehabilitation Providers

Presented by Jason Falvey, PT, DPT, GCS, PhD and Kyle Ridgeway, PT, DPT, CCS

Overview of Hospital Readmission Reduction Programs: Relevance to Rehabilitation Providers

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Hospital readmissions have become an important patient, hospital, and health care issue. Ideal care transition models have been proposed but do not include rehabilitation therapists. Physical function is independently associated with hospital readmission risk, yet little evidence links rehabilitation to reduced readmissions. This overview course will frame the problem of hospital readmissions, present current care transition models, and then outline risk factors for readmissions. Lastly, we will propose how rehab professionals can fit into efforts to reduce readmissions and improve care transitions.

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Physical Function as a Biomarker for Hospital Readmissions

Presented by Jason Falvey, PT, DPT, GCS, PhD and Kyle Ridgeway, PT, DPT, CCS

Physical Function as a Biomarker for Hospital Readmissions

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Reducing readmissions is a major goal of many health care organizations. Despite data suggesting that physical and functional factors are independently associated with readmissions, ideal care transition models and hospital readmissions reduction programs lack involvement of rehabilitation professionals. This course will outline the relationship between impaired physical function across the spectrum of care and hospital readmission risk. We will discuss the role of rehabilitation professionals in identification and timely management of functional deficits related to hospitalization.

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Patient- and Family-Centered Interventions to Prevent Readmissions

Presented by Jason Falvey, PT, DPT, GCS, PhD and Kyle Ridgeway, PT, DPT, CCS

Patient- and Family-Centered Interventions to Prevent Readmissions

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Ideal care transitions and efforts to reduce hospital readmissions must involve the patient and family/caregivers. This course will introduce general concepts on engaging patients and families in discharge planning, care transitions, and self-management/monitoring post discharge. Concepts from motivational interviewing and therapeutic alliance will be connected to specific subjective information, patient/family goals, and patient education content.

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Evidence-Based Rehabilitation to Reduce Readmissions

Presented by Jason Falvey, PT, DPT, GCS, PhD and Kyle Ridgeway, PT, DPT, CCS

Evidence-Based Rehabilitation to Reduce Readmissions

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Although individuals at risk for hospital readmission span diagnoses and patient populations, common sequelae of a hospitalization are shared. Further, the principles guiding interventions (e.g., focus and intensity) may be similar. This course will review specific direct patient care interventions and other contributions (e.g., communication, discharge recs, decision-making) for patients at risk for hospital readmissions. Case examples for specific diagnoses and patient presentations will be explored.

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