Transitional Outcomes Program

Transitional Outcomes Program

Modeled after national best practices, our Transitional Outcomes Program (TOP) is a patient-centered service designed to increase patient safety and reduce readmissions to acute care facilities.

Our program helps our patients move between healthcare practitioners, settings, and home as their conditions and care needs change. We use a collaborative, interdisciplinary approach to provide early identification and assistance with transitional needs of specific patient populations.

Patient engagement, education, and empowerment are integral to our program’s success.

How TOP Works

Patients at risk for readmission can be referred to the program at any time during his or her hospital stay by any member of our interdisciplinary team.

Once a patient is identified for TOP, members of our interdisciplinary team work together daily with the patient and family members to help reduce or eliminate risk factors for readmission. There are a variety of risk factors that are considered. These may include but are not limited to, medications taken incorrectly, lack of mobility, bowel and bladder issues, and inability to procure needed supplies and services.

We follow patients for a minimum of 30 days post-discharge to ensure appropriate and effective community reintegration.

TOP Components

Key components of TOP include:

  • Early and ongoing education and intervention
  • Validation of patient/family understanding of critical components to prevent readmission
  • Follow-up care coordination beginning at time of discharge. This includes physician follow-up appointment confirmation, addressing medication compliance issues that may arise at home, as well as an ongoing risk assessment with appropriate interventions. We coordinate care post-discharge up to 30 days.

About Ernest Health

Elkhorn Valley Rehabilitation Hospital is part of Ernest Health. Ernest Health provides specialized medical and rehabilitative services to our patients through our rehabilitation and long-term acute care hospitals. We treat patients who often are recovering from disabilities caused by injuries or illnesses, or from chronic or complex medical conditions.

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Guiding Principles

As our Guiding Principles state, we promote a healing and nurturing environment where everyone is treated with dignity and respect. We are first and foremost passionate patient caregivers and team members, connected at our core by the treatment needs of our patients.

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Our Leadership Team

Our leadership team brings extensive healthcare experience to Elkhorn Valley Rehabilitation Hospital. We invite you to meet them and learn more about why they are passionate about healthcare.

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Community Commitment

At Elkhorn Valley Rehabilitation Hospital, we are committed to being good neighbors and responsible corporate citizens in the Casper community.

We do this through not only the healthcare services we provide, but through our philanthropic efforts.

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