Transitions are key in cutting readmissions
Nurses make calls after discharge
A key to the success of Monmouth Medical Center’s readmission program is ensuring that patients get the care they need after discharge and understand their treatment plan and medication regimen.
“We moved to a true transitional model of care and work at all levels of care to ensure that patients avoid an emergency department visit or a hospital admission,” says Eleanor Rapolla, BSN, CCM, director of case management for the Long Branch, NJ, medical center.
The hospital’s cardiac RNs, all nurses with a critical care background, call all patients discharged with a primary diagnosis of heart failure on Day 3 and Day 14 after discharge, no matter where the patients are. They ask a series of questions about the patients’ understanding of their treatment plan and medication regimen, whether they have gotten their prescriptions filled, and if they have a follow-up appointment.
“The call on Day 14 is important because it a very vulnerable period. Patients may be behind in following their treatment plan or medication regimen. If they are experiencing shortness of breath, the nurse can decide on what action to take,” Rapolla says.
The cardiac nurse practitioner evaluates patients on Day 1 of admission and begins educating the patients, answers questions, and makes a follow-up appointment with the outpatient heart failure management program after discharge whenever possible. “We try to book a follow-up appointment within seven days of discharge to home whenever possible,” Rapolla says.
The unit-based case managers and heart failure nurse practitioner work together on a discharge plan and engage patients in the outpatient heart failure management program.
When patients come into the program the first time, they spend an hour and a half with the nurse practitioner, who conducts a full assessment and goes over the treatment plan. Then the dietician meets with them for a half hour to go over their dietary plan. “We have found that people often are overwhelmed when they are in the hospital and don’t remember what they’re supposed to do at home and need a lot of reinforcement in the beginning,” Rapolla says.
The nurse practitioner typically sees the patients twice a week after the initial visit, tapering off to weekly and monthly visits as needed.
The nurses from the Visiting Nurse Association who are seeing the patients in their home partner with the nurse practitioner to make sure the patient understands and is following his or her treatment plan.
“When all providers at all levels of care work together, it results in better outcomes for the patients,” Rapolla says.
Source
- Eleanor Rapolla, BSN, CCM, director of case management, Monmouth Medical Center, Long Branch, NJ. email: [email protected]
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