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Program cited as CMS Best Practice
When Medicare patients with multiple chronic illnesses are discharged from the hospital, a team of nurses from Carondelet Health Network and care coordinators and navigators from the Pima Council on Aging provide follow-up care coordination in the home and by telephone for 30 days after discharge from the hospital. In some cases, patients may be followed for 45-60 days, according to Donna Zazworsky, RN, MS, CCM, FAAN, vice president community health and continuum care for Carondelet Health Network, based in Tucson, AZ.
The Carondelet-Pima Council on Aging Transitional Care Navigation program, a partnership between the two organizations, is participating in the Community-Based Care Transition program developed by the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center to test models for improving care transitions from hospitals to other settings and for reducing readmissions for high-risk Medicare beneficiaries.
CMS has called the program a National Best Practice in reducing hospital readmission rates.
The program is underway at Carondelet St. Joseph’s Hospital and Carondelet St. Mary’s Hospital, both located in Tucson, AZ. It is staffed by nurses from the Carondelet Health Network who conduct medication reconciliation and educate patients on self-management, and care coordinators/social workers, called coaches, from the Pima Council on Aging who help patients access needed social services and coordinate care between providers. They are assisted by Pima Council on Aging navigators. The navigators enter the patients into the database and track where they are in the system, answer the telephone and make outreach calls to patients.
The Care Transitions team members help patients follow their discharge plans and medication regimens, educate them about their diseases and signs and symptoms that indicate their conditions are worsening, provide the social support patients need to maintain their health, and facilitate communication between care providers, Zazworsky says.
"This program is not to be confused with home health. We provide care coordination, not skilled nursing care. Our team works with patients on self-management, education, and medication reconciliation," Zazworsky says. Many patients have social issues that make it difficult for them to follow their treatment plan. These include a lack of transportation, financial instability, low healthcare literacy, lack of social support, and cognitive issues.
"We find that oftentimes patients or family members believe they can manage after discharge but quickly learn that it’s more difficult than they thought. Having a nurse and a care coordinator come out to the home helps people learn how to better manage their chronic illness," Zazworsky adds.
Before the program began, a multidisciplinary team from Carondelet Health System researched the literature on readmissions prevention and customized interventions based on Boston University’s Project RED (Re-engineered Discharge).
"We met with nursing, the hospitalists, case managers, and pharmacists, and went over each item in the Project RED discharge process and clarified which discipline has the responsibility for each item," Zazworsky says. For instance, the bedside nurses educate the patient on their disease, the hospitalist reviews lab values and tests, the pharmacists go over medication changes, and the case managers check to make sure all points are being addressed at discharge.
The team developed patient education tools based on color-coded zones for each diagnosis to alert patients what to do when their condition changes. Signs and symptoms in the Red Zone mean that the patient should seek medical attention immediately. If patients have signs and symptoms in the Yellow Zone, they should call their physician office. The Green Zone indicates that the patient has his or her condition under control. So far, the team has developed the Zone tool for heart failure, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, and renal failure and is working on additional diagnoses.
The treatment team in the hospital begins educating patients on how to use the zones. The Care Transitions nurse continues the education during home visits and follow-up phone calls.
Patients who are eligible from a medical aspect are identified for the program by the case managers at the two participating hospitals, using the LACE tool, a standardized risk assessment tool, within the first 24 hours after admission. (LACE stands for Length of Hospital Stay, Acuity on Admission, Comorbidity, and Emergency Department Visits.) Patients also are assessed for social risks. "Some patients may be at low risk medically but have a high risk on social issues," Zazworsky says. The program takes on 150 to 170 new patients each month.
A member of the team, usually a nurse, visits the eligible patients in the hospital, explains the program to them, and gets their agreement to participate. "Often, the patient doesn’t enroll the first time they are contacted. Many want their spouse, son, or daughter to hear about the program and asks that the nurse come back later," she says.
A pharmacy technician completes a medication history while patients are in the hospital. "Medications are a huge issue. We start while the patient is in the hospital to find out what they were taking at home and what they will be taking after discharge so we can make sure there are no duplicative or conflicting medications," she says.
Nurses visit the high-risk patients within 48 hours of discharge and make additional visits if necessary. The nurses conduct medication reconciliation and compare the medications in the home with what was prescribed at the hospital. They educate patients about their disease, how to self-manage it, and reinforce how to use the zone tool. They accompany patients to their follow-up physician appointment, answer any questions and reinforce what the physician said. The nurses contact the moderate-risk patients within 48 hours of discharge and visit them in their homes as soon as possible. They make regular phone calls to check on the patients and answer any questions or concerns.
The coaches visit patients with social issues in their home as needed and check on them by telephone to make sure the services they need are in place.
The team is piloting a tele-visit program that connects the patients with team members and a pharmacist via laptop. Family members can receive a link and participate in the face-to-face visit.
Some nurses in the transition program work on the floor at the hospital and spend one day a week making home visits and helping with phone calls.
"This is a wonderful way to have a hospital nurse learn about the continuum of care. When they work on the floor, they start thinking differently," she says.
Carondelet set up a preferred provider network with a home health agency, skilled nursing facility, long-term acute care hospital (LTACH) and an infusion therapy provider. The providers use the Zone tools and other materials developed by Carondelet to ensure that patient education is consistent.
Members of the provider network meet regularly with the Care Transitions team. The providers agree to follow the team’s protocols and guidelines, to report readmission rates, and to work with the team on reducing readmissions. "We have asked them to define their transition program so we will know what happens when patients go from the skilled nursing facility to home," she says.
The Aging Transitional Care Navigation Program has its roots in Carondelet’s 2009 pilot project to reduce readmissions rates for heart failure.
Patients targeted for the program were beneficiaries of Medicare or Mercy Care, Carondelet’s Medicaid plan. They were referred by cardiologists or identified by a risk assessment tool for heart failure.
"In the first year, we recognized that many of the patients had issues around social needs and set up an internship for social work students from the university," Zazworsky says.
"When the Centers for Medicare & Medicaid Services’ Innovation Center came out with the Community-Based Transition program, we already had a lot of elements in place," she says.