Magazine article American Nurse Today

Transitional Care-The Pathway to Integrated Care Delivery: Clinical and Community Partnerships Reduce Hospitalization and Emergency Department Visits

Magazine article American Nurse Today

Transitional Care-The Pathway to Integrated Care Delivery: Clinical and Community Partnerships Reduce Hospitalization and Emergency Department Visits

Article excerpt

Healthcare delivery in the United States is not sustainable in its present state, and nurses across the country need to take the lead in redesigning it. One group of clinical nurse specialists is spearheading the design and implementation of value-based, integrated care in rural Vermont.

Making the transition

The clinical nurse specialists in our American Nurses Credentialing Center Magnet[R] designated hospital are integral members of the care team, but with decreasing inpatient census we risked losing this valuable resource. To retain these care professionals, we began a literature search that revealed the successful work of Mary Naylor at the University of Pennsylvania. Naylor used nurse practitioners as transitional care nurses (TCNs) to help patients navigate from one setting to another, bridging the gaps in communication, collaboration, and education. TCNs partner with patients and families, sharing pertinent information with care providers, assisting with appropriate referrals, and providing education about symptom and medication management for chronic diseases. (See Transitional care model.)

Building relationships

With a goal of engaging clinical and community partners in this program, TCNs initially met with the clinical leaders of community agencies and the hospital to identify gaps in care. Then TCNs held group meetings with frontline staff from those facilities and agencies, asking where they saw gaps, where they needed help, and what was and wasn't working. Getting to know colleagues who play major roles in care delivery and building relationships became the foundation of the project. Home care and medical home agencies worried about duplication of effort and turf issues, so mapping out workflows and providing assistance when requested was the first step. We wanted to create a cohesive, interdisciplinary team to better meet our community's needs.

Solving the puzzle

After learning where help was needed, TCNs began spending time in skilled nursing facilities, shadowing home care and hospice nurses, learning about case management, and witnessing care delivery in primary care practices. The total picture of each individual patient's journey became clearer; TCNs learned that a hospital stay is one small part of the story, with a minimal impact on health outcomes.

TCNs discovered that many patients didn't understand their complex discharge plans, didn't take medications correctly, and had overwhelming social issues including needing assistance to pay for medications, food, and heat for their homes. The expectation that patients would understand their chronic disease and manage their symptoms was unrealistic. For the first time, the pieces of the puzzle came together.

Measuring results

In the 3 years since this project began, all primary care practices affiliated with the Southwestern Vermont Health Care system have chosen to partner with the TCNs. Each TCN works with three to four primary care practices, identifying high-risk, chronic care patients who've had multiple hospitalizations and emergency department (ED) visits and may benefit from assistance. More than 1,000 patients have participated in the program with over 700 allowing home visits.

Implementing TCNs led to a 49.7% decrease in hospitalizations and a 11.3% decrease in ED visits in the 180 days after intervention among these patients. Scores on satisfaction surveys are high, with multiple positive comments from patients and families, and healthcare costs for patients in the program have fallen. Reduced rates of hospitalization and ED visits mean less revenue for the hospital, a goal for healthcare reform that's difficult to embrace in a fee-for-service model, but will be rewarded in a value-based environment.

As part of annual nursing education, the TCNs have shared insights with their inpatient colleagues. As a result, projects are underway to change how we discharge patients and involve them in the process:

* creating refrigerator magnets with color-coded instructions for managing chronic obstructive pulmonary disease (COPD) and heart failure symptoms in all settings

* providing medication boxes along with assistance from healthcare providers to educate patients about proper use

* partnering with clinical pharmacists to ensure cost-effective medication ordering and to develop strategies that improve medication adherence, such as pharmacists providing medication education in hospitals, primary care practices, and homes

* sharing standardized heart failure, COPD, and diabetes education with providers in various healthcare settings to improve patient understanding. …

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