Transitional care nurses help prevent readmits
Communication is key to program success
At MedStar Franklin Square Medical Center in Baltimore, discharges are facilitated by a multidisciplinary transitional care team, led by a transitional care nurse who fosters communication between disciplines and collaborates with post-acute providers to ensure that transitions are smooth and timely.
All-cause readmissions have dropped from 10.43% in fiscal 2013 to 8.8% in the spring of 2014. Heart failure readmissions dropped by 2% in the same period, says Jan Lear, RN, ACM, director of case management at MedStar Franklin Square Medical Center in Baltimore.
"The transitional care nurses are a key to the success of the program. As coordinators of the unit-based transitional care team, they make sure everything is in place for a safe and effective discharge and that patients have appropriate post-discharge interventions," Lear says.
The hospital’s readmission reduction program focuses on the diagnoses most frequently readmitted, including myocardial infarction, heart failure, pneumonia, vascular surgery, chronic obstructive pulmonary disease, and chronic renal disease. Care for patients with those conditions is managed by a multidisciplinary team led by a transitional care nurse. Other team members include representatives from nursing, case management, social work, pharmacy, and a home care representative, Lear says.
The hospital’s readmission reduction program started on the cardiac unit with heart failure and myocardial infarction, says Debbie Steelman, RN, MS, transition team leader.
The heart failure team meets four days a week and reviews all the patients in the hospital with heart failure or myocardial infarction. They discuss what the discharge disposition is likely to be, go over every patient and determine what the barriers are to discharge, and any services the patients will need after discharge.
The cardiology physician champion meets with the team once a week and attends walking rounds with patients the team has identified as benefiting from extra teaching. "The team goes into the patients’ rooms as a group and discusses the diagnosis, what treatment patients are getting, what they need to do to manage their condition, and encourage them to ask questions," Steelman says. A cardiologist from MedStar Franklin Square Medical Center also rounds weekly on heart failure and chronic obstructive pulmonary disease patients who have been transferred to a subacute facility with which the hospital has partnered.
The pharmacists on the team provide medication reconciliation and education to high-risk patients. They fill new prescriptions for discharging patients and offer a hotline number patients can call after discharge if they have questions or concerns, Steelman says.
The team has three options for post-discharge interventions. Patients who are debilitated and need more intense therapy may be transferred to a subacute rehabilitation facility. If patients require less intense monitoring, they are referred to MedStar Visiting Nurse agency or the home health agency of their choice. Patients who are referred to a subacute facility or home health must meet Medicare requirements for coverage. Those who do not qualify or require one of the options are discharged home and followed for 30 days by the transitional care nurse, she says.
The transitional care nurse sees patients while they are still in the hospital and begins providing education using the teach-back method. The goal of the education is to instruct patients on what they can do to manage their condition, Steelman says.
The nurses give patients a heart failure booklet that reinforces the education they receive in the hospital and has a place for patients to record their daily weight and symptoms. They encourage the patients to take the book with them to their physician appointment, she says.
The team has determined that teaching heart failure patients how to weigh themselves is critical to the success of the discharge, Steelman says. "Some patients weigh themselves at different times of day and wearing clothing of different weight. This does not give an accurate picture of their condition. We teach them to weigh at the same time and dressed the same way. If they don’t have a scale at home, the hospital can provide one at a discounted price," she says.
The transition care nurses follow up with patients three to five days after discharge and call them back periodically, depending on the patient’s needs, for 30 days. They encourage patients to get a follow-up appointment with their primary care physician or specialist. Patients who can’t get in to see their doctor within five days can come to the hospital’s Transition Clinic, which opened in the spring and is staffed by nurse practitioners.
"We tried making appointments for the patients while they were still in the hospital but got a lot of resistance. A lot of times, they didn’t know their schedule or they had to arrange for someone to take them," Lear says.
The transitional care nurses make sure the patients have gotten their prescriptions filled and are taking their medication correctly, reinforce education, and communicate with the patient’s primary care physician or specialists about the hospitalization and the treatment plan, Lear says.
If patients are struggling to follow their discharge plan or need more support, the nurse can arrange for a home health nurse to make a one-time visit at no charge to the patient. "It’s helpful to have another set of eyes on the patient," Lear says. "The nurse can make sure they know how to weigh themselves, perform medication reconciliation, and check the refrigerator and cabinets to see if there are problems with their diet. The nurse visits have been very valuable, not only to help the patients with their immediate needs but to determine when patients need extra education or assistance."
When patients are being discharged with home health, the transitional care team works closely with MedStar VNA to facilitate a smooth transition to home and to make sure patients have all the resources they need to manage after discharge. When needed, the home care nurses can set up telemonitoring devices to check blood pressure and weight to keep track of how patients are doing in between visits. They communicate with the patients’ physicians when there is a change in condition, Steelman says.
The hospital has developed a partnership with Genesis Healthcare, which operates a subacute rehabilitation facility. Representatives from the hospital and the subacute facility have developed collaborative programs for chronic obstructive pulmonary disorder and heart failure to provide continuity in the teaching and standards of care as patients transition, she says.
The transitional care team is working with Genesis Healthcare to develop a palliative care program and has added a hospice liaison to the team. "We’ve noticed that many of our heart failure patients in their 80s and 90s still are in full code status, even if they are in the final stages of the disease, because no one has had the conversation about comfort care," Lear says. "Patients often are stuck in a cycle of exacerbation and treatment, then exacerbation and rehospitalization all over again. We are working to evaluate patients for appropriateness for comfort care and make them aware of the option. We feel this is very important for quality patient care."
When patients who have been discharged within 30 days come into the emergency department, the case managers work with physicians to explore options to readmitting them. The hospital’s software system alerts the case manager when patients who have been discharged from the hospital within 30 days come to the emergency department. "The case manager reviews the medical record to find out the patient’s discharge destination and works with the physician to decide if the patient can be stabilized and discharged to the subacute rehabilitation facility they were just discharged from rather than being readmitted," Lear says.
