Tag Archives: Readmissions

2015 JQS Award Nominee

Meritage ACO: Improving Care Transitions, Reducing Readmissions

  “It looks like you’ve had another exacerbation of your COPD. I really would like you to start using home oxygen. And there are some other medications I would like to adjust here…” William hears the ER doctor at Marin General Hospital (MGH) but can’t help letting his mind wander. This is his third time […]


Andrea Kmetz, RN, and Marie Robertson Andrea Kmetz, BS, RN is the Director of Care Management and Quality Assurance at the Meritage Medical Network and Meritage ACO. She is responsible for multidisciplinary complex case management and care transitions coaching for 41,000 enrollees as well as multitude of quality initiatives. Marie Robertson, BS, is Quality Management Coordinator for the Meritage Medical Network and Meritage ACO. She works with Andrea to implement quality assurance initiatives in addition to coordinating community wellness programs, CME events and other projects.

Andrea Kmetz, RN, and Marie Robertson, BS has 2 post(s) at EngagingPatients.org

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Patient-Centered Care

HERE TO HOME: Effectively Engaging Heart Failure Patients in Their Care

As a Planetree hospital, Griffin Hospital is committed to engaging patients and families with access to information and education. In 2012, we identified a lack of consistent patient disease education with teach-back which contributed to a high readmission rate for Heart Failure. We introduced “HERE TO HOME,” a program to address communication and patient education […]


Kathleen M. Martin, RN, BSN, CCM, CPC-H Kathleen M. Martin, RN, BSN, CCM, CPC-H, has been Vice President of Patient Safety and Care Improvement since 2006 and currently leads the Quality Performance Improvement initiatives for Griffin Hospital, a 160-bed community acute care facility. Prior to this position, Kathleen served as an Assistant Vice President of Case Management and Medical Records since 1983. Kathleen was instrumental in developing the Palliative Care Program in collaboration with the Connecticut Hospice which enables patients to experience patient-centered end of life care. Kathleen currently leads a community collaborative “Gateway To Health” to reduce heart failure readmissions with area skilled facilities and home care agencies. Kathleen also has facilitated bereavement and support groups for the community for the past 25 years. She is a member of CMSA, AAPC and serves on the QA Board of the Connecticut Hospital Association.

Kathleen M. Martin, RN, BSN, CCM, CPC-H has 1 post(s) at EngagingPatients.org

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