Care Transitions Program

1. Care Transitions Program Sherrill Rhodes, MSN, HCAP Divisional Director Quality & Service Excellence Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health

2. Focus & Priorities • 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

3. Inpatient Setting

4. Inpatient Setting • Transition Nurses across the facility • Modified LACE assessment tool • All “at risk” patients on designated units are followed until discharge • Coordination with social workers, utilization nurses, & charge nurses • All post-discharge needs are addressed including: home health, DME, medications, first MD appt, etc…. • Follow up and Handoff

6. Community Setting

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

8. Resources Provided • Ongoing health education & promotion • Home visits (education & resource-focused, not home health or direct patient care) • Advocacy with providers • Assistance with various funding programs: FQHC, County, etc. • PPH grant-funded Ector County Health Care Coalition resources: • Medication assistance with discount programs • Transportation assistance/vouchers • Minor equipment for self-monitoring (BP cuffs, scales, glucometers) • Education materials

9. Outcomes • Since program implementation: • -over 1200 patients navigated on the outpatient side • -ER visits reduced significantly in target population, readmission rate for population approximately 10-15% • -All patients in program are set up with PCP for long-term management • -Community partnerships established with FHQC-look alike, APS, local charity organizations, faith-based organizations • Most common reason for readmission: • -Noncompliance/lack of patient follow-up, inability to obtain medications, homeless population, alcoholism & drug use

10. PPH Grant Outcomes • For the 18-month funded period (1/1/12-6/30/13): • -13.9% reduction in hospitalizations for COPD/Asthma • -24.5% reduction in hospitalizations for CHF • -10.8% reduction in hospitalizations for all 9 adult PPH conditions combines • -27.2% reduction in hospital charges to Medicaid • -15.5% reduction in hospital charges to the Uninsured population

11. Future Plans • Transition nurse expansion into surgical service lines, critical care areas • Full expansion of navigation services into ER • Possible expansion of navigation services in maternal/child areas • Ongoing data collection & analysis

12. Questions