Overlake Hospital Medical Center has become one of the first hospitals in the Puget Sound area to implement a new Care Transitions Intervention program to facilitate patients’ smooth transition from hospital to home and to eliminate unnecessary hospital readmissions.
Initially, Overlake is focusing on heart failure patients age 65 and older – those most at risk for readmission – and will expand the program over time to include all Overlake hospital inpatients. The program is managed by Overlake’s Senior Care staff that provides coordinated care and comprehensive services for adults over age 55.
Care Transitions Intervention is a nationally recognized, evidence-based program developed in 2003 by Eric A. Coleman, MD, MPH, Associate Professor of Medicine at the University of Colorado, Denver. The Centers for Medicare and Medicaid encourages the implementation of such programs to improve care quality, reduce preventable readmissions within 30 days of discharge and reduce overall healthcare costs for Medicare patients.
“Care Transitions is designed to help discharged hospital patients successfully care for themselves at home so they can recover fully and stay healthy,” said Joan Luster, Manager of Overlake’s Senior Care program. “While all patients currently receive discharge instructions from their doctor or nurse before leaving the hospital, it’s very difficult for many people to remember and follow all the instructions, especially those who are elderly and managing multiple health conditions.”
Luster said the program enables an Overlake nurse to spend critical one-on-one time in the patient’s home to coach them through caring for their health condition after they leave the hospital.
Overlake’s Care Transitions Intervention consists of a 30-day program conducted by a registered nurse that begins with an initial contact when patients are still in the hospital. Follow-up visits include one in-home visit within three to seven days after discharge, and three follow-up phone calls to check on patients’ progress, help them manage their medications, prepare for doctor visits and answer questions.
Lynn Shapely, an Overlake registered nurse involved with the program, said it helps patients better understand their condition and empowers them to better self management.
“For example, the fact that patients weigh themselves every day and understand why is what’s important,” Shapely said. “They now know that an increase of three pounds in one day isn’t something to hide, thinking someone will get mad at them for eating too much. They now understand that the weight gain is due to fluid retention and should trigger a call to the doctor.”
A recent study published in the Journal of the American Medical Association reports that heart failure patients who have follow-up visits with a healthcare professional within seven days of discharge have a 15 percent lower 30-day readmission rate than those who do not have the follow-up.
The intervention is designed to coach patients to ensure they follow four key aspects of heart failure self-care:
– manage medications to ensure medications are taken as directed and don’t have any potentially harmful medication interactions.
– maintain a personal health record to note recovery progress, changes in health, questions to ask their doctor.
– schedule a follow-up visit with their primary care physician/specialist.
– identify possible red flags and immediate actions to take to address a worsening condition.
Based on empowerment theory and goal setting, the program focuses on helping patients set their own goals for success so they are fully engaged in the process and can track their progress using measures important to them. The role of the Care Transitions nurse is that of coach rather than traditional caregiver. Instead of taking care of all the patient’s needs for them, the RN teaches patients to ask questions, problem-solve and find out the answers on their own. This approach has proven to help patients better care for themselves once the intervention is complete.
