Transitional care pilot program shows promise

Communication at hand-offs improved

A nurse practitioner-led transitional care program has helped improve communication between hospital and community care providers and facilitated a timely transfer of patient information, according to a study of a two-year pilot project.1

"We developed this program so when patients get to the hospital, providers would have all of the necessary baseline information on the patients," says Maria Tereza Lopez-Cantor, MA, ANP-BC, CCRN, a nurse practitioner with Internal Medicine Associates — PACT at Mount Sinai Medical Center in New York, NY.

"The nurse practitioner serves as a consultant," Lopez-Cantor adds.

It's an intensive intervention, notes Theresa Soriano, MD, MPH, director of the Mount Sinai Visiting Doctors Program and director of the Mount Sinai Chelsea-Village House Call Program. Lopez-Cantor and Soriano were among the authors of a study on the program.

The Mount Sinai Visiting Doctors Program is a primary care practice that operates outside of the hospital. The transitional care program helped the practice bridge a communication gap between its physicians and hospital providers, Soriano says.

The program enrolled Visiting Doctors' patients who were admitted to the hospital. There was a daily census of seven to 25 patients admitted, Lopez-Cantor says.

"One reason we did this program was because our physicians are in the field all day, and by the time we made it back, many things might have happened with a patient in the hospital," she explains. "And we couldn't discuss the patient with hospital physicians until the end of the day."

The study found that the program's financial implications were reassuring, although it had not reduced hospital length of stay and readmission rates significantly.1

"We failed to show statistically significant outcomes in terms of length of stay or readmission rates because these were very sick patients who were nursing home-eligible with multiple comorbidities," Lopez-Cantor says.

"We think there are improvements in costs because of the focus groups we ran for providers," Soriano says. "People said they felt more comfortable discharging patients home knowing we would be following up, and before this program we weren't able to see patients right away."

Other benefits included better medication reconciliation and medication adherence and improved patient and provider satisfaction, they say.

"Patients loved that there was someone they could identify who was following through with their care and that they didn't feel alone in the hospital — they had someone advocating for them," Lopez-Cantor says.

"One big benefit is having the planning and treatment goals continued after discharge with nothing lost along the way," Soriano says.

Initially, a grant funded salaries for two nurse practitioners for the program. When the grant ended, the hospital paid for one nurse practitioner position. The Visiting Doctors program began a new team-based approach, but the hospital continued with a revised transitional care approach.

Although the hospital was not able to bill for this transitional care service, it proved financially beneficial because it helped the hospital increase its net revenues because hospital staff were better able to document each patient's medical complexity, Soriano and Lopez-Cantor say.

"A patient might have been admitted for pneumonia, but he also could have diabetes and chronic obstructive pulmonary disease and dementia," Soriano explains. "This makes for a more complicated patient and results in greater payments to the hospital."

Physicians do not have time to find every medical problem a patient has experienced in recent years, so they base their documentation on what they see, she notes.

"Even the best-meaning hospital physician, looking in hospital charts, won't see two years of home visits we've been providing because these aren't documented in the system," she says.

The NP-led transition care program makes sure they have this kind of information. Also, as hospitals and community providers transition to electronic medical records, this communication issue might improve.

Here is how the transitional care program works:

The nurse practitioner receives an alert when the patient is hospitalized.

"When patients of our program were hospitalized, we had two nurse practitioners who would be alerted, and they'd go into the hospital that first day," Soriano says.

When the Mount Sinai Visiting Doctors Program started the initiative, hospital providers had limited information about the patient's community care and advanced directives, so the NP would bring that information to hospital medical teams.

"We'd have communication put in the patient's chart in the hospital, listing the reason for admission, a medical list up-to-date, contact people, a code status, and next of kin," Soriano says. "Giving them this information was helpful in creating a channel of communication between the inpatient team and our program."

Once the patient is admitted to the hospital, Lopez-Cantor would find the hospitalist or attending physician and discuss the patient's case and discharge barriers. She'd also meet with the hospital's social worker for that floor.

Nurse practitioner addresses social issues.

The NP also could facilitate a family meeting to discuss end-of-life issues or safe discharges between the hospital and community providers, she adds.

"From the very beginning we are in touch with the social workers to plan out the discharge for this patient," Lopez-Cantor says. "We give them information about home care, nursing services in place, safety issues in the home, and that sort of thing."

Also, if the patient has social issues that make it difficult to return home, then they could address that, as well during the hospitalization, she adds.

"I'd type up things that were going on in the home, like a family dispute," she says.

The program facilitates medication reconciliation.

"We review all the medications the patient would be going home with so when the patient is discharged home, it would be a smoother transition," Lopez-Cantor says. "We review all the medications at home on the post-discharge visit to make sure there are not mistakes or errors."

Occasionally, Lopez-Cantor has made a visit to the patient's home and found prescriptions still sitting on the dining room table two to three days after discharge.

"When I'm in the home I call in those prescriptions to make sure they get all the medication they need," she adds.

Communication was thorough.

"A lot of the communication was face-to-face," Lopez-Cantor says. "I also developed a progress note, which I put in the chart as a summary of the patient, including all medical problems, all medications, advanced directives, lab work, and any significant test done on an outpatient basis that might contribute to better management of the patient in the hospital."

The improved communication also helped hospital staff prevent a duplication of health care services.

For instance, the hospital physician might decide to order a CT scan for a patient, and the nurse practitioner would inform them of a CT scan that already had been done on an outpatient basis, Soriano explains.

Lopez-Cantor also meets with patients and gives them a card with her contact information. She tells them to call her anytime.

"When I got back to my office, I did follow-up on the patient," she adds. "If there are any issues, I'll get involved, but I don't want to step on too many toes, so I'm there for support and on behalf of the patient and the program."

When the hospital plans the patient's discharge, staff can contact Lopez-Cantor and arrange a discharge visit to discuss who will be visiting the patient post-discharge.

"Most of the time I did the visit post-discharge," she adds.

The post-discharge visit usually took place within one week of discharge, and it often was done as a joint visit with a home health agency nurse, Soriano says.

"But for half the patients, there was no skilled nursing need, so the nurse practitioner was responsible for only transitional care that the patient had upon discharge," she says.

"One of the necessities for this program to work is having nurse practitioners, or it could be physician assistants, in this setting," Soriano says.

"We felt the clinical complexity of patients at baseline, who were hospitalized from our program, tended to be much sicker than regular patients, and we wanted somebody with a higher level of clinical experience," she adds.


1. Ornstein K, Smith KL, Foer DH, et al. To the hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people. J Am Geriatr Soc. 2011;59(3):544-551.


• Maria Tereza Lopez-Cantor, MA, ANP-BC, CCRN, Nurse Practitioner, Internal Medicine Associates – PACT, Mount Sinai Medical Center, 1 Gustave Levy Place, Box 1087, New York, NY 10029. Telephone: (212) 824-7228. Email:

• Theresa Soriano, MD, MPH, Director, The Mount Sinai Visiting Doctors Program, Director, The Mount Sinai Chelsea-Village House Call Program, One Gustave Levy Place, Box 1216, New York, NY 10029-6574. Telephone: (212) 241-4141.