Transition nurses follow patients after discharge

PCPs team up with hospitals

To eliminate gaps in care after their members have been hospitalized, Cigna Medical Group has assigned RN care coordinators to local hospitals to act as a bridge between the primary care practice and the hospital and has a dedicated team of physicians, pharmacists, and nurses who see the majority of patients for their first follow-up visit.

Cigna Medical Group is the medical practice division of Cigna Healthcare of Arizona and is a Level-3 NCQA-recognized Patient-Centered Medical Home with 23 healthcare centers and two convenience care centers located throughout Phoenix.

“We started the Transition of Care Nurse Program eight years ago because we were seeing some very significant gaps in care. We identified opportunities for improvement that included post-discharge follow-up and a clinically integrated model on the front end,” says Robert Flores, MD, medical director, population health.

The organization began the Custom Care After the Hospital follow-up program in 2012 to ensure that patients being discharged from the hospital have a timely follow-up appointment.

“We know that the most crucial time for the patients is 24 to 72 hours after discharge. If something goes wrong and the patient doesn’t have someone to deal with the problem, they wind up in the emergency department or back in the hospital,” Flores says.

The organization determined that there were gaps in information between the hospitals, the primary care physicians, and specialists that constituted risks for patients being readmitted to the hospital. In addition, some patients were confused about their disease after discharge and were not receiving the recommended post-discharge services, he says.

The organization assigned six RN care coordinators to seven hospitals to work with its Medicare Advantage patients. “We wanted to establish communication between the hospital system, especially the emergency department physicians, and the primary care physicians,” he says.

The idea was for the care coordinators to share information from the patient’s primary care records that would help the physician make a decision about admitting the patient.

At the beginning, the plan was for the nurses to coordinate the full spectrum of care from the beginning of the stay and after discharge. “When we started, hospital systems were not ready to accept co-management of their patients. Now the healthcare world is starting to change and hospitals are realizing that there is great value to having utilization information on the front side of an admission. Hospitals have not always taken full advantage of the program until recently, but now hospitals are very much aligned with our interest in preventing readmissions as well as first hospitalizations,” he says.

When primary care practices and hospitals share information, it results in better care for the patients, Flores says. “We can provide the results of tests that have been done, information on medication they are taking, and a list of problems. All of that is very helpful and it eliminates the hospital staff having to rely on patients for that information,” he says.

The Transition of Care nurses are employed by the practice. Their primary role is to act as a bridge between the Cigna Medical Group’s primary care practices and the hospitals. They visit the hospital and make rounds on the Medicare Advantage patients, interact with the patients and family members as well as the hospital case managers and hospitalists, and often case managers from the health plan.

“They are an extension of our office practice into the hospital,” Flores says.

The Transition of Care nurses establish a relationship with the patients and work with the hospital case managers and hospitalists on a discharge plan. They let the patients know that they will contact them within 24 to 48 hours after discharge. The patients are receptive to the post-discharge calls because they are expecting them and because they have already have a relationship with the nurses.

The Transition of Care nurses make at least one post-discharge telephone call to the patients whether they are being discharged from the acute care hospital or a skilled nursing facility. If the patient needs additional support, the nurses may follow them for several weeks, or refer them to the physician group’s general care coordinators, depending on the type and extent of their needs.

The nurses follow a specific set of questions during the post-discharge calls to make sure nothing has been missed. They assess the patients’ health stability, make sure that they are doing well at home, check to ensure that the durable medical equipment has arrived, verify that they have a caregiver and that they can perform activities of daily living. They ask questions about the patients’ activity level to assess the need for physical therapy, occupational therapy, and other home health services. They go over the discharge orders, review medication, and conduct medication reconciliation.

They make sure the patients have follow-up visits scheduled with their primary care physicians, and specialty programs such as anticoagulation clinics. The nurses make sure there are no gaps in care and that the primary care practice has all records from the hospital stay as well as the discharge summary.

If the patients are discharged to a skilled nursing facility, the same nurse follows them and picks up after they are discharged. They make sure the patient doesn’t have gaps in care as they transition from the acute care hospital to the skilled nursing facility and make sure the staff at the receiving facility have all the information they need to care for the patient.

Cigna Medical Group has begun a new program to ensure that patients have a timely follow-up visit with a primary care provider after discharge. Called Custom Care After the Hospital, the program includes a multidisciplinary team of caregivers who see the large majority of patients for the first post-discharge visit. The team is dedicated to the Custom Care program and includes pharmacists, and nurses in addition to physicians.

“One of the dilemmas of post-discharge follow-up is the ability to guarantee an available visit shortly after discharge. This special team fills that gap and gives the Transition of Care nurse another team of providers to refer patients to as they come out of the hospital,” he says.

The team in the Custom Care program takes at least an hour to review the patient’s medical history, medication regimen, and need for community resources and schedules further visits as needed. They typically follow patients for 30 days after discharge. “Nobody is in a rush. It’s a satisfying visit for the patient and the team,” Flores says.

After the visit, the team sends a summary of the visit to the primary care provider.

The organization has gotten positive feedback from both the patients and the hospital system on the program. “Patients are always amazed and pleased that their primary care provider is aware of and involved in care in the hospital,” he says.