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Easing Transitions from Hospital to Home

Through a two-year grant project, Crozer-Keystone hospitals are focusing on transition care for patients 65 and older.

Funding for the Care Transition program was provided by a $400,000 grant from the U.S. Department of Aging’s Administration on Aging and The Centers for Medicare and Medicaid Services—one of 16 such grants nationwide — that was awarded to CKHS and the County Office of Services for the Aging (COSA). The program was originally introduced at Taylor Hospital, but was later brought to Springfield Hospital and, soon, to Crozer-Chester Medical Center.

Launched in February 2011, the project focuses on bridging the gap for patients who meet specific medical and psychosocial criteria and reducing readmission rates. “What we wanted to do was break down the silos of care, get everyone on the same page and put the patient back in the center of the discussion,” says Barbara Alexis Looby, director of Senior Health Services for CKHS.

Built on a patient care management trial that Looby initiated at Taylor, the program is based on the highly regarded Transitional Care Model (TCM) and utilizes the services of a dedicated full time advanced practice nurse (APN). Patients are screened 24-48 hours after they arrive at the hospital with continual monitoring throughout their stay. The APN and a COSA assessor based at Taylor work with hospital staff, the patient’s primary care physician and family to identify services that will be needed once the patient goes home.

Appointments with doctors and specialists are scheduled within three to five days of discharge. Once the patient leaves the hospital, the APN conducts home visits and makes routine calls to make sure the patient is getting necessary medical attention and complying with instructions for follow-up. The APN will also help coordinate community-based services such as personal care, phone monitoring and transportation. Along the way, the APN provides medical education to the patients to ensure their participation in getting and staying healthy.

Initially, the program set a goal of helping 235 patients over the two years; 237 were enrolled before one year was even complete. The hospital readmission rate for the patients program has been 7.59 percent — far below the national average of 20 percent.