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 servicesTo reduce avoidable readmissions and ER visitsIncrease community resource utilizationPromote 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 dischargeCoordination with social workers, utilization nurses, & charge nursesAll post-discharge needs are addressed including: home health, DME, medications, first MD appt, etc…. Follow up and Handoff

Community Setting

Community 3 Community Nurse NavigatorsFocus on patient education, empowerment and connection with community resources Make post discharge calls at 14,21, 30 days & PRNAccept community & self referralsOpen 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 programsTransportation assistance/vouchersMinor 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 PlansTransition 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