Tucson Medical Center keeps its readmission rates low by having transitional coordinators work closely for patients with chronic disease who are at risk for readmissions.

  • An analysis of readmitted patients determined that many who were rehospitalized were elderly with chronic diseases.
  • The transitional coordinators are three experienced nurses with knowledge of chronic disease who work closely with the care team and follow patients for up to 30 days after discharge.
  • The hospital arranges for post-acute providers to come to the hospital to see the patients referred to them for services.

As part of its readmission reduction program, Tucson (AZ) Medical Center developed the role of transition coordinator to work closely with patients with chronic diseases who are at risk for readmissions.

The hospital has reduced its penalties for readmissions in the first three years of the CMS readmission reduction program and expects no penalties for 2016, says Elizabeth Maish, RN, MSN, CPHQ, chief nursing officer at the 641-bed hospital.

“Tucson is a small city with a population of about one million. We are a big hospital and have a strong, long-term relationship with the post-acute providers. All of this contributes to our success in reducing readmissions,” Maish says.

The hospital has a stable and experienced case management department that experiences little turnover, Maish says. “The case management department is very important and is essential to our bottom line and to our patient flow. Coordination of care is so pivotal to readmissions and management of patients, and our case managers are very involved and get good results,” Maish says.

The hospital has an average census of more than 400 patient a day and a high Medicare acuity index. “This tells us that our population is older and more chronically ill,” Maish says.

When the case management department began focusing on readmission rates, they analyzed patient populations, diagnoses, and demographics and determined that many of the patients who were being readmitted were elderly with chronic diseases.

“We found that there were commonalities among the patients who were impacting our readmission rates. Every patient is a little different but many at-risk patients have chronic diseases, such as diabetes and heart disease, that contribute to readmissions,” she says.

The team also found that behavioral health issues were another factor in readmissions, she says. “We know that depression is very prevalent in older adults with chronic conditions. These patients are very difficult to place. They aren’t difficult to treat, but you can’t treat somebody over a four-day hospital stay and expect that they will be completely stable from a medical, spiritual, and mental health standpoint. They need follow-up after discharge,” Maish says.

The hospital created the role of transition coordinator to work with at-risk patients who have chronic conditions, and filled the slots with three experienced RNs who were knowledgeable about chronic diseases. Two of the nurses were case managers and the third was an intensive care nurse.

“These nurses know the clinical piece and treatment protocols for managing chronic diseases and they also know the best environment in which to place these patients after discharge,” she says.

The transition care coordinators focus on the at-risk patients with chronic diseases, leaving the unit-based case managers free to work with other patients on the unit, Maish says. They access the electronic medical record each day for a report that identifies potential patients based on primary and secondary diagnoses and their healthcare utilization for the last five years. “Our average length of stay is 4.4 days, so it’s essential that we identify these patients early in the stay,” Maish says.

The transition coordinators typically coordinate care for 7 to 12 patients at a time, depending on the hospital census, Maish says. They work closely with the medical team and help them follow the hospital’s best care pathways. They work with the rest of the team to create a disease-specific treatment plan for the patient stay and a discharge plan that provides everything the patient needs for a safe discharge, Maish says.

Education of patients and caregivers is a major component of the chronic disease program.

“Whether patients are going home, to a skilled nursing facility, an assisted living facility, or to live with family, the most important piece of preventing readmissions is preparing patients to transition to the next phase,” she says. “The chronic disease care coordinators bring together all the aspects of the patient, including physical status, spiritual and mental health, medication profile, patients’ understanding of their disease and medication regimen, and communicate it with the people at wherever the patient is going.”

The transition coordinators work as a team with the treating physician and the clinical team to coordinate the transition plan and to make sure that the next provider of care, whether it’s the primary care physician, a skilled nursing facility, or a home health agency, has the information they need to take care of the patient’s needs.

They follow up with patients and their caregivers as needed for up to 30 days after discharge, she says.

When a patient is ready for discharge to a post-acute facility or has a home health referral, the transition coordinator sends the facility the pertinent parts of the patient record over a secure Internet connection and follows up with a phone call to the nurse who will be caring for the patient.

“We have strong connections and long-term relationships with the post-acute facilities and home health agencies in Tucson and we hold them accountable for the outcomes experienced by our patients. We work closely with them and share quality data and patient feedback with them,” Maish says.