Hallmark Healthcare’s Community-based Care Transitions project created the position for transition facilitators who visit at-risk patients in their homes and achieved significant decreases in readmissions.

  • Transition facilitators work as a team with inpatient case managers, a nurse practitioner, and a pharmacist.
  • They see at-risk patients in the hospital, visit them in their homes within three days of discharge, set up any community services needed, and follow them by telephone for 30 days.
  • The nurse practitioner and pharmacist make home visits to patients who need extra assistance in following their treatment plan or medication regimen.

A program that includes post-discharge home visits for at-risk Medicare patients has resulted in significant reductions in readmissions for the more than 2,000 patients enrolled in Hallmark Healthcare’s Community-based Care Transitions Program instituted by CMS.

A key to the success of the program was creating a new position for transition facilitators — lay staff who visit the patients in their homes within three days of discharge and follow up by telephone for 30 days, says Cheryl Warren, MS, RN, CMAC, chief clinical integration officer for Hallmark Healthcare, a network of community hospitals and health centers in the Boston area.

The goal of the program is to reduce readmissions and costs of care by improving the transition of patients from the inpatient setting, Warren says.

The health system has seven transition facilitators who have undergone six weeks of intensive training. The transition facilitators are not licensed staff, but most have a background in social work, case management, or a related healthcare field, Warren says. “They are supporting patients and coordinating services rather than handling clinical needs,” Warren says.

They work as a team with the inpatient case managers, a nurse practitioner dedicated to the program, and a pharmacist to oversee transitions from the inpatient setting to home or a skilled nursing facility, she says.

Some transition facilitators work full-time; others part-time. They make rounds in the hospital in the morning and see patients in their homes in the afternoon.

In preparation for beginning the Community-based Care Transitions Program in December 2013, the Hallmark case management team conducted a root-cause analysis to determine why patients were being readmitted. The team determined patients with diseases such as heart failure, chronic obstructive pulmonary disease, and pneumonia were at highest risk and designed the program to target at-risk Medicare beneficiaries.

The inpatient case managers refer patients who are at risk to the transition coordinators, who rotate taking new referrals. Often, the patients live alone with little or no support system, rely on an assistive device for mobility, and have deficits in activities of daily living. “Most often, they need meal deliveries, help with obtaining or paying for medication, transportation to appointments, or housekeeping assistance,” Warren says.

The transition facilitator meets the patient while he or she is in the hospital, and explains the program. The facilitator conducts an assessment to determine the patient’s support at home, establishes a baseline level of function, and determines what services the patient will need after discharge. “They begin to establish a relationship with the patients and compile an inventory of what they anticipate the patient will need. Then they arrange for the services when the patient is about to be discharged, and visit the patients after discharge,” she says.

The transition facilitator makes follow-up phone calls for 30 days and hands the patient off to the primary care provider’s office, or the ambulatory case manager.

The nurse practitioner conducts rounds with the transition facilitators and evaluates patients enrolled in the program. He or she identifies the patients who would benefit from a nurse practitioner visit in the home, such as patients with frequent admissions, those on multiple medications, or those who need extra education about their treatment plans. In the home, the nurse practitioner checks vital signs, goes over the clinical teaching, and collaborates with the patient’s primary care provider and adjusts medications or changes treatment plans when necessary.

The pharmacist conducts a chart review on 100% of the patients in the hospital and determines who may need special teaching on diet and medication, who are taking multiple medications and are adding more prescriptions, and others who might benefit from a pharmacy visit a home. If the patient is taking a large number of medications, the pharmacist visits the home and reviews all the medicines, and educates the patients on which to take and when.

“Everybody enrolled in the program gets a visit from the transition facilitator. The team decides on a case-by-case basis if a visit from the nurse practitioner or pharmacist is needed,” Warren says.

The home visits allow the team to identify problems that could lead to a readmission and take action before the patient gets worse, and spot social needs that the patient didn’t reveal during the assessment, Warren says. The transition coordinator makes sure the utilities are working, that there is food in the kitchen, and conducts a safety check. In some cases, the facilitator arranges more community services to meet the patient’s needs.

“The transition coordinators find out things in the home that we never would know otherwise. Sometimes patients have the same medication they were prescribed in the kitchen cabinet or the medicine cabinet and are taking both,” she says. That’s when the transition facilitator calls in the pharmacist. If the patient is showing signs and symptoms that indicate his or her condition is getting worse, the facilitator calls the nurse practitioner.

The transition facilitator alerts the patient’s primary care provider about the hospital stay and checks with durable medical equipment providers, home health agencies, and other organizations to be sure the equipment or services are in place.

Most patients get just one visit from the transition facilitator, but occasionally, the facilitator feels the patient could benefit from a second visit, Warren says.

The transition facilitator and a nurse practitioner oversee patient care for 30 days. They make sure patients have follow-up appointments and transportation, have filled their prescriptions, are following their discharge instructions, and have any equipment they need. For example, the discharge instructions may call for patients to weight themselves daily, but they don’t have a scale.

In some cases, the team visits patients who are transferred to a skilled nursing facility. “The team participates in care coordination and discharge planning activities in the facility, and makes home visits and follows up when the patient is discharged,” she says.