Transitional care model proves its worth
Mary Naylor's model put to the test
Recent literature highlighting the high number of hospital readmissions has brought the issue front and center. Coordinated care, an integral indicator of quality, means managing patients, especially those at high risk for rehospitalization, in the hospital and beyond. It means educating patients on their conditions, medication regimens, and self-care instructions; intervening when post-discharge symptoms come up; and ensuring that follow up visits with primary care physicians or other providers are scheduled. Transitioning patients from hospital to home or any post-acute care in a successful way means a lot of things, which have a big impact on the continued health of the patient and of the hospital.
There are myriad discharge or transitional care models out there today. And one of the most discussed is that of Mary Naylor, PhD, RN, professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania, school of nursing.
Joan Doyle, RN, MSN, MBA, executive director at Penn Home Care and Hospice Services, part of the University of Pennsylvania Health System, is part of a pilot using the model with the Hospital of the University of Pennsylvania. The pilot focused on patients with congestive heart failure, chronic obstructive pulmonary disease, and frail elders with several comorbidities at high risk for readmission.
Within the pilot, 112 patients completed the intervention. The readmission rate associate with the project, between September 2008 and July 2009 was 13.2%, or 76 of the 112 patients.
Patients are followed by an advanced practice nurse while in the hospital. Within 24 hours of discharge, the nurse follows up with the patient and continues to make regular home visits with ongoing telephone support.
If the patient has problems post-hospitalization, he or she can call the nurse to discuss it. "It's what we call 'red flag management' — to get the patients before they spiral down," Doyle says. "It's an emphasis on early identification and response to health care risk and symptoms and avoidance of those adverse events that lead to readmissions."
The nurses are charged with actively engaging patients and their families or informal caregivers in education, disease management, and support. They also facilitate communication to and among health care providers — physicians, nurses, social workers, discharge planners, or any other providers involved in the patient's care. They schedule post-discharge follow-up appointments for patients and often will accompany patients on those visits.
They ensure patients have their medications and that they're taking them, they educate about diet compliance, and they help patients manage any other symptoms that may crop up while at home.
All the nurses in the program undergo an orientation program and educational programs designed for the program by Naylor.
Penn's clinical strategies are under the auspices of what it has coined its Blueprint for Quality. "That framework is really an institution-wide event in that the chief medical officers and the chief nursing officers really spearheaded it," Doyle says.
Within that framework, they undertook the pilot using Naylor's transitional care model. Doyle says they've identified several layers that she says "make the biggest difference in transitions in care and the overarching goal of how we prevent unanticipated readmissions."
• Triaging and identifying patients "at greatest risk for readmission and identifying what their post-acute needs are" is one of the crucial steps. Doyle says one element found to be "really effective is real-time readmissions feedback."
For every readmitted patient, there is a focused review looking at what happened — what was the reason the patient was readmitted — and then assurance that the patient receives a post-acute follow up. "So we try to make sure that if they have come back in, when they go back out again, they have an assessment and whether there are other things we need to put into place."
• Interdisciplinary care planning played a big role in the pilot's success. In each of the hospitals in the system, there is a unit-based leadership team comprising a triad of a nurse, a physician, and a quality officer. "So each one of the inpatient units at our three hospitals can drill down on their individual metrics and start to look at their own patient populations, their own readmission rates," Doyle says. So discharge involves a whole team.
• Primary care follow up, medication management across the continuum, and education/red flag managements all have been crucial to Penn's success.
Recent literature highlighting the high number of hospital readmissions has brought the issue front and center. Coordinated care, an integral indicator of quality, means managing patients, especially those at high risk for rehospitalization, in the hospital and beyond.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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