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Transitional Care Program Experiences Excellent Outcomes

In Brief:

  • Crozer-Keystone offers a grand-funded project at Taylor and Springfield hospitals focuses on transitional care for patients 65 and older.
  • Initially, the program set a goal of helping 235 patients over the two years – and at the end of the first year, 275 patients were enrolled.

 

Mary Anne Leonard

Mary Anne Leonard, CRNP, transitional care nurse,
right, connects with a patient.

 

 

 

 

 

 

 

 

 

 

Caring for older adults presents unique and complicated challenges that go beyond the clinical attention they receive in the hospital. That’s why a grant-funded project at Taylor and Springfield hospitals focuses on transitional 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 the County Office of Services for the Aging (COSA) and Crozer-Keystone Health System (CKHS)

The two-year project, which launched in February 2011, focuses on bridging the gap between acute and post-acute care services. It targets patients who meet specific medical and psychosocial criteria with the goal of sustaining elderly patients in their own environment and reducing readmission rates. “What we hoped to accomplish with this grant funded initiative was to create opportunities to minimize what historically had become disjointed care. We believed if we collectively delivered patient cantered care and breakdown silos it would prove to be beneficial to older adults and their families. ” says Barbara Alexis Looby, director of Senior Health Services for CKHS.

Built on a patient care management trial that Looby initiated at Taylor last year, 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 (such as physicians, nurses, social workers and case managers) as well as 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 prior to discharge and are scheduled within three to five days of discharge. Once the patient leaves the hospital, the patient is followed by home care.

The APN also conducts home visits and makes routine calls to ensure the patient is getting necessary medical attention and complying with all discharge instructions and commits to follow-up care. While at home, patients are often assigned a Care Manager through COSA who will work closely with the APN to 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 improving their health status.

Initially, the program set a goal of helping 235 patients over the two years – and at the end of the first year, 275 patients were enrolled. The hospital readmission rate for the patients participating in the program has been 7.59 percent—far below the national average of 20 percent. These low rats are significant because they demonstrate that managing patients’ medical and social needs from hospital to home sustains them in the community.

“We have exceeded our own expectations. We’ve had a positive impact on sustaining patients’ health and reducing the number of readmissions to the hospital. Patients have also reported high satisfaction rates with the service,” Looby says. “I’ve seen patients reach their own personal goals, whether it’s getting to the hairdresser once a week or getting to church on Sundays, and there’s gratification in knowing we’ve helped them get there.”

For more information about the programs provided through Senior Health Services, call 1-800-CKHS-KEY (1-800-254-7539) or visit www.crozerkeystone.org.

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