Our hospital developed a multidisciplinary team of nurses, social workers, advanced practice providers, and physician navigators to assist patients after they are discharged home from the acute-care setting. This team uses an interdisciplinary approach, connecting with stakeholders across the patient’s entire healthcare continuum to address gaps in care and support patients during this vulnerable period of time. Partnering with patients, families, and our community has been shown to improve patient outcomes and empower them to be more engaged in their health. This session will review the structure of our program with outcomes, and outline strategies for building a transitional care program.
Tool: Multidisciplinary transitional care team with five components; Community Coordination, Complex Care Transitions, Access Navigation, RN Outreach, and a Virtual Clinic. Each component plays a key role in addressing patient needs efficiently and effectively after they are discharged home. This presentation will outline each component to support reproduction at other facilities.
Problem: Transitions in care mark a vulnerable period for patients. Our hospital evaluated 30-day readmission rates and patient satisfaction scores noting opportunities to improve in each of these areas. We also found that individuals with complex conditions such as CHF, COPD, and Pneumonia have ongoing needs after discharge home.
Tool Selection: We evaluated current evidence-based practice strategies and incorporated components based on our population’s needs and available community resources. It took time to cultivate relationships with stakeholders and establish clear escalation pathways for identified patient needs. Using readily available resources and improving efficiency showed value by improving patient outcomes over time.
Usage: RNs make strategic outreaches to all patients and families after being discharged home from the acute care setting. Calls address key patient needs with clear escalation pathways to resolve identified concerns. The other components of the program act as a support system for resolving needs and supporting patients with chronic conditions.
Results: Quarterly Medicare readmission rates declined from 10.7% in 2022 to 9.4% in 2023. CHF (15.4% to 10.5%), COPD (18.2% to 15.4%), and PNA (16.8% to 13.5%). 48-hour return rates for ED patients were lower for those who were contacted vs those not, controlling for baseline indicators (2% vs 7%, OR:2.5, p<0.001).
