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Care Transitions Program

Care Transitions Program. Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health Medical Center Health System . To improve the overall patient experience and continuum of care through risk-based screening and navigation services

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Care Transitions Program

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  1. Care Transitions Program Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health Medical Center Health System

  2. To improve the overall patient experience and continuum of care through risk-based screening and navigation services • To reduce avoidable readmissions and ER visits • Increase community resource utilization • Promote health & wellness in the community setting Focus & Priorities

  3. Transition Nurses • Modified LACE assessment tool • All “at risk” patients on designated units are followed until discharge • Coordination with social workers & case managers • All post-discharge needs are addressed including: home health, DME, medications, first MD appt, etc…. Inpatient Setting

  4. 3 Nurse Navigators • Focus on patient education, empowerment and connection with community resources • Make post discharge calls at 14,21 & 30 days • Accept community & self referrals • Open referral process Community

  5. Medication assistance with discount programs • Transportation assistance/vouchers • Advocacy with providers • Home visits (education & resource-focused) • Minor equipment for self-monitoring (BP cuffs, scales, glucometers) • Ongoing health education & promotion • Assistance with various funding programs Resources Provided

  6. Since program implementation: • 420 patients assisted • ER visits reduced significantly, readmission rate for population approximately 15-20% • Most common reason for readmission: • Alcoholism, noncompliance, homeless population Outcomes

  7. Roles Defined Navigator Liaison *Coordinates outpatient care *Helps clients navigate the service systems *Develops a network of community resources *Provides avenues for prevention and education *Maintains program documentation and participates in ongoing program evaluation and reporting *Is notified of hospitalized member needs via the Navigator *Recruits congregational members into the Faith and Health Network *Shares community resources *Facilitates wellness activity participation *Is able to visit patient as a GUEST/VISITOR

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