In partnership with the Visiting Nurse Association of Hudson Valley, Sound Shore Medical Center in New Rochelle, N.Y., recently launched the Rapid Response and Care Transitions programs to decrease the number of ED visits and hospital admissions and readmissions.
Available 24/7, the Rapid Response program focuses on individuals with chronic diseases or the elderly, who can benefit from support services when they return home after an ED visit.
Targeting patients who are stabilized and do not require a hospital admission, the programs goal is to deliver services to patients at home as quickly as possible. If indicated, the home care nurse can see the patient within two to four hours after discharge, said Cornelia Schimert, RN, BSN, director, business development and community relations, VNA of Hudson Valley.
“In this joint and coordinated effort, we can strengthen the continuity of care for our patients and keep them safe at home,” said Schimert, who has seen an increase in program awareness and referrals since it began in November.
Once a patient is medically stabilized in the ED and does not need to be admitted to the hospital, ED staff makes a referral to the VNA, which confers with the ED physician, nursing staff and patient and family about services, such as a home health aide, nursing care or physical therapy.
Upon discharge, a nurse from the agency sees the patient at home and performs a comprehensive assessment; reviews the patients discharge instructions; reinforces instruction on proper use of all medications; and teaches the patient to be alert to changes in their condition.
“An in-home evaluation also includes a determination about the need for telehealth monitoring and other services, such as hospice or palliative care or medical equipment,” Schimert said.
Heading up the Care Transition program is Vivian Gardner, RN, BSN, FNP-BC, care transition coach, who initially sees hospitalized patients diagnosed with congestive heart failure, pneumonia and acute myocardial infarction. Trained in the Coleman Care Transition Intervention Model from Denver, Gardner checks up on eligible patients upon discharge and for 30 days postdischarge with phone calls and one or more home visits, depending on the patients needs.
Gardner coaches patients in medication management and medication reconciliation and guides them in developing their own personal health records.
She also reviews discharge instructions, what to do when experiencing symptoms and how to prepare questions for the follow-up primary healthcare provider visit.
“Its all about empowering the patient. For example, I help them recognize their own ‘red flags that mean their health condition is worsening, role play a phone call to their PHP to make their follow-up appointment within seven days after discharge or help them figure out where they can get a prescription filled more reasonably,” said Gardner, who also helps patients identify their own health goals and what steps they need to take to reach them.
“We have seen that 96% of patients who have been invited to participate in our Care Transition program have chosen to participate,” said Rhonda D. Ruiz, RHIA, MPH, assistant vice president, operations, Sound Shore Health System.
“With one-on-one training and support, patients in the two programs become more knowledgeable, more self-reliant and more confident,” Schimert said.
Janice Petrella Lynch, RN, MSN, is a regional nurse executive.