Care Transitions Program
description
Transcript of Care Transitions Program
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Care Transitions Program
Diana Ruiz, DNP, RN-BC, CWOCN, NEDirector of Population & Community Health
Medical Center Health System
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
Focus & Priorities
Transition Nurses Modified LACE assessment tool All “at risk” patients on designated units
are followed until discharge Coordination with social workers & case
managers All post-discharge needs are addressed
including: home health, DME, medications, first MD appt, etc….
Inpatient Setting
3 Nurse Navigators Focus on patient education,
empowerment and connection with community resources
Make post discharge calls at 14,21 & 30 days
Accept community & self referrals Open referral process
Community
Medication assistance with discount programs
Transportation assistance/vouchers Advocacy with providers Home visits (education & resource-
focused) Minor equipment for self-monitoring (BP
cuffs, scales, glucometers) Ongoing health education & promotion Assistance with various funding
programs
Resources Provided
Since program implementation: 420 patients assisted ER visits reduced significantly,
readmission rate for population approximately 15-20%
Most common reason for readmission:
Alcoholism, noncompliance, homeless population
Outcomes
*Coordinates outpatient care
*Helps clients navigate the service systems
*Develops a network of community resources
*Provides avenues for prevention and education
*Maintains program documentation and participates in ongoing program evaluation and reporting
*Is notified of hospitalized member needs via the Navigator
*Recruits congregational members into the Faith and Health Network
*Shares community resources
*Facilitates wellness activity participation
*Is able to visit patient as a GUEST/VISITOR
Navigator
Liaison
Roles Defined