Transcript Care Transitions Program

Care Transitions Program
Sherrill Rhodes, MSN, HCAP
Divisional Director Quality & Service Excellence
Diana Ruiz, DNP, RN-BC, CWOCN, NE
Director of Population & Community Health
Focus & Priorities
To improve the overall patient experience and
continuum of care through “risk-based”
screening and navigation services
To reduce avoidable readmissions and ER
visits
Increase community resource utilization
Promote health & wellness in the community
setting
Inpatient Setting
Inpatient Setting
Transition Nurses across the facility
Modified LACE assessment tool
All “at risk” patients on designated units are
followed until discharge
Coordination with social workers, utilization
nurses, & charge nurses
All post-discharge needs are addressed
including: home health, DME, medications, first
MD appt, etc….
Follow up and Handoff
Community Setting
Community
3 Community Nurse Navigators
Focus on patient education, empowerment
and connection with community resources
Make post discharge calls at 14,21, 30 days &
PRN
Accept community & self referrals
Open referral process on the inpatient side
Resources Provided
Ongoing health education & promotion
Home visits (education & resource-focused, not home
health or direct patient care)
Advocacy with providers
Assistance with various funding programs: FQHC,
County, etc.
PPH grant-funded Ector County Health Care Coalition
resources:
Medication assistance with discount programs
Transportation assistance/vouchers
Minor equipment for self-monitoring (BP cuffs, scales,
glucometers)
Education materials
Outcomes
Since program implementation:
-over 1200 patients navigated on the outpatient side
-ER visits reduced significantly in target population, readmission rate
for population approximately 10-15%
-All patients in program are set up with PCP for long-term
management
-Community partnerships established with FHQC-look alike, APS, local
charity organizations, faith-based organizations
Most common reason for readmission:
-Noncompliance/lack of patient follow-up, inability to obtain
medications, homeless population, alcoholism & drug use
PPH Grant Outcomes
For the 18-month funded period (1/1/12-6/30/13):
-13.9% reduction in hospitalizations for COPD/Asthma
-24.5% reduction in hospitalizations for CHF
-10.8% reduction in hospitalizations for all 9 adult PPH
conditions combines
-27.2% reduction in hospital charges to Medicaid
-15.5% reduction in hospital charges to the Uninsured
population
Future Plans
Transition nurse expansion into surgical service lines, critical
care areas
Full expansion of navigation services into ER
Possible expansion of navigation services in maternal/child
areas
Ongoing data collection & analysis
Questions