Transition manager is liaison between teams
Executive Summary
At University of Utah Health Care, a transition case manager acts as a liaison between the outpatient care team at community clinics and the inpatient care team.
• The transition navigator works with case managers at the hospital and the clinics to make sure both have the information they need to coordinate care for the patient.
• The transition navigator visits patients in the hospital and works with the unit case manager to make sure the discharge plan will work.
• To further smooth transitions, the patients receive a one-page sheet that summarizes their discharge instructions, follow-up appointments, and medication regimen.
Program cut readmissions by 23%
By embedding a transition navigator within the hospital team to act as a liaison between the outpatient care team and the inpatient care team, University of Utah Health Care has reduced 30-day readmissions by 23% for patients who work with the navigator compared to patients who are not seen by the navigator, according to Stephanie Wallace, RN, manager of care management for University of Utah Health Care.
"Many times, the care team at the community clinic has information that will help the inpatient team create a successful discharge plan. Before the navigator program started, the hospital team and the clinic team didn’t have a way to communicate regularly. The transition navigator ensures that all of the discharge paperwork gets to the proper place so the patient, the family members, the care managers at the clinic, and the patient’s provider all know the plan of care," says Wallace, who, before assuming her current position, was the health system’s transition manager.
The transition navigator’s priority is patients who have a primary care provider at University of Utah Health Care’s community clinics. The navigator gets a list of patients who have been admitted to the hospital each morning and screens them to determine if the patients have an established relationship with a primary care provider in one of the health system’s clinics. If patients don’t have a primary care physician, the transition navigator helps them find one.
The clinics are notified electronically if they have a patient admitted or if surgery is scheduled, and the navigator works with the clinic staff to get information that can help with the patient’s discharge plan.
For instance, when she was a transition navigator, Wallace worked with a surgical patient who was disabled and whose spouse also was disabled. The patient told the hospital team that her mother would be able to care for her after discharge.
"She failed to tell the hospital team that her mother was in her 90s, was frail, partially blind, and didn’t drive," Wallace says.
The care manager at the clinic alerted Wallace to the woman’s situation at home before the patient was admitted for the planned surgery.
"I was able to set up a team meeting with the case manager on the floor before the patient was admitted, and the case manager on the floor knew in advance that a skilled nursing placement was the best option and was able to help the patient get used to the idea," she says.
Without the intervention, the patient may have been discharged to home with no support and no transportation to her follow-up visit, resulting in a potential readmission, Wallace points out.
Visiting patients
The navigator visits patients in the program in their hospital room and lets them know she is working with their primary care provider. "When I had the job, I told patients that my job was to make sure that the hospital staff understands the outpatient plan and that when they got ready to leave, I would make sure the staff in the clinic understood what the hospital team wanted the plan of care to be," she says.
The navigator checks on the patient throughout the hospital stay and becomes more involved as the patient gets ready for discharge, working closely with the hospital case manager to make sure the discharge plan will work. Whenever possible, the navigator also meets the person who will be taking care of the patient after discharge.
"The transition navigator is able to communicate in a way that shows continuity of care with the outpatient setting. The patients saw me as a direct link to their primary care provider while they see the case managers and staff nurses as hospital employees," she says.
The navigator visits the patients after the discharge nurse has completed the discharge teaching, asks if there are questions, and emphasizes the need for follow-up.
For instance, if a pneumonia patient has orders for a chest X-ray in six weeks, the transition navigator will explain why the procedure is important, and then makes sure the patient gets a reminder call before the procedure is scheduled.
The navigator rounds with the hospital providers and shares information from the clinic care manager. "It gives the treatment team a bigger and clearer picture of what is going on with the patient," she says.
The transition navigator also sees patients in the emergency room and acts as a liaison between the care managers in the clinic and the emergency department staff.
Connecting with case managers
After patients are discharged, the care managers at the health center get a list of who was discharged and call the patient within 24 to 72 hours and ask a series of questions, such as if the patient has a follow-up appointment, or if they have questions about their medication regimen.
When patients need a lot of follow-up, the navigator may be involved, but most of the time, the navigators get patients connected to case managers in the health centers to facilitate outpatient resources.
Elderly patients particularly like the navigator interventions, Wallace says. "They find it comforting that their providers in the clinics know they are in the hospital and know what is going on so they don’t have to go through everything during their follow-up appointment," she says.
It took a while for the inpatient staff to understand and appreciate the navigator’s role, Wallace says.
"In the beginning, it wasn’t clear that what I was doing was very different from what the case managers do. Once they realized it was a collaborative and complementary effort, the case managers felt supported and the providers felt like patients were getting the attention they deserve," she says.
