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EssenMed House Calls’ TOC Program Helps St. Barnabas Reduce 30-day Readmission Rates

Bronx, NY (September 17, 2015) – It is with great pride that EssenMed House Calls applauds our esteemed partner, St. Barnabas Hospital, for being recognized by the medical community as a pioneer in hospital reduction of 30-day patient readmission rates.

In their efforts to drastically reduce 30-day readmission rates, St. Barnabas Hospital revisited the process of patient recovery, from admission to post-discharge. As part of this process, St. Barnabas Hospital identified EssenMed House Calls as a necessary asset to provide excellent post-discharge care. Since February of 2013, St. Barnabas Hospital and EssenMed House Calls have joined forces to provide high quality medical attention to discharged patients through EssenMed House Calls’ Transition of Care Program (“TOC”). Upon receiving the referral, EssenMed House Calls contacts patients within 24-48 hours to schedule an initial TOC visit. The vast majority of initial visits occur within four to seven days of discharge.

Using discharge summaries provided by the healthcare facility, EssenMed House Calls follows patients, most of whom are elderly or chronically ill, for 30 days immediately following discharge. During this time, EssenMed House Calls engages patients in telephonic as well as face-to-face check-ins and coordinates and arranges for any supplementary specialty medical or non-medical services needed to rehabilitate high-risk patients back into their community, all in an effort to avoid unnecessary re-admissions into hospitals or emergency rooms.

Additionally, during the 30 day period, EssenMed House Calls collaborates with any specialty provider along with the patient’s primary care physician to ensure an effective transition into the community. After the 30 day TOC period is concluded, EssenMed House Calls provides the patient’s primary care physician a  comprehensive summary of the patient’s plan of care, bringing the TOC process to full circle.

The TOC program started in response to the 2012 Hospital Readmissions Reduction Program, a byproduct of the Affordable Care Act. This new legislation was introduced to combat excessive 30-day readmission rates in hospitals. EssenMed House Calls seized the opportunity to implement the TOC program, formalizing many of the interventional components it already had in place for its long-term house call patients, to improve the quality and efficiency of in-home patient care for this newly targeted patient population.

“The first 30 days following a hospital stay are the most critical to ensuring that patients properly recover and avoid complications,” said Dr. Sumir Sahgal, EssenMed House Calls’ chief Medical Officer. “We have found this model to be very cost-effective in reducing hospital readmissions as well as provide patients with the caliber of personalized care management that leads to increased patient satisfaction.”

Following the TOC program’s 4 pillars (medication management,  early warning interventions, patient centered health record, and primary care provider/specialist follow up), EssenMed House Calls strives to provide effective, quality healthcare for post-discharge patients in all five boroughs of New York as well as Westchester. EssenMed House Calls continues to proudly serve as the largest house call provider in the state of New York, and provides compassionate, multilingual support to patients in need.

St. Barnabas Hospital has worked diligently in conjunction with EssenMed House Calls to transform handling of patients with chronic conditions and, since 2011, has amassed a 14 percent reduction in 30-day readmission rates. Impressively, St. Barnabas Hospital, assisted by the continued efforts of EssenMed House Calls holds an astoundingly low readmission rate of 0.12% of its entire Medicare patient population in 2015.   At a time when almost all urban hospital face increasing penalties for readmission by Center for Medicare and Medicaid (CMS), St. Barnabas is the rare exception with reducing readmission each year, having the lowest penalties (0.19%) among those hospitals this year.  Such achievements are the result of fluid partnership between EssenMed House Calls and St. Barnabas Hospital and devout dedication toward consistent, quality healthcare.

Since partnering in 2013, EssenMed House Calls’ TOC providers cared for 2,400 of St. Barnabas Hospital chronically-ill patients and looks forward to continued successful relations with St. Barnabas Hospital.   For more information on EssenMED House Calls, visit or call 718.294.6200.