Nurses connecting with patients at risk of readmission before discharge — and following up after they are home — has significantly reduced readmission rates at three hospitals in the Bronx. “What made it successful was the contact our nurses had [with patients],” said Janet Kasoff, EdD, BSN, senior director, Center for Learning and Innovation, Montefiore Medical Center, one of three nonprofit hospitals participating in the Bronx Collaborative, which led the initiative.
The collaborative found that 17.6% of the 500 patients receiving two or more interventions were readmitted to the hospital within 60 days of discharge compared with 22.8% of patients receiving one intervention and 26.3% of the control group of 190 patients who received the current standard of care, a phone call after discharge.
Any patient in the program who was readmitted received a visit from a specially trained home health nurse for an environmental assessment and to evaluate factors that could have contributed to the readmission.
Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center, along with insurers EmblemHealth and Healthfirst, joined together to improve care and lower costs, with the first issue addressed being elimination of preventable readmissions, collaborative spokesman Steve Matthews said.
Clinicians designed the nurse-led Care Transitions Program, blending components of different evidence-based protocols into a workable, standardized program.
“The design task force felt an RN was best equipped to understand the needs and help formulate a plan of care,” Kasoff said. “Nurses are autonomous in their capability to diagnose nursing problems.”
An experienced home care, case management RN or care transition manager at each hospital receives a list of medical patients age 50 or older at risk of readmission, as determined by diagnosis and admissions during the previous year. The RN obtains the persons consent to participate and share data, presenting the program as an enhancement to care.
“We develop a relationship early on,” said Natalie Cruz, RN, a care transitions manager at Bronx Lebanon, who visits the patient daily during that stay, teaching about the diagnosis, medications, red flag symptoms and self-care.
The same nurse follows up by telephone between 48 and 72 hours, seven to 14 days post-discharge, and between 15 and 60 days post-discharge to review medications, identify concerns and verify the completion of the follow-up physician visit, considered an important component of the program.
“Patients really like the attention and [having] someone they can reach out to and help them navigate the system,” Cruz said. “They need a little more care and understanding of how things work in the hospital.”
Cruz finds her background as a nurse helpful in the role and enjoys the rewards of engaging patients in their care and making changes that improve their lives.
“This is the wave of the future,” Cruz said. “Nurses need to be more involved in educating their patients and managing their health so they dont have to be readmitted to the hospital.”
The care transition manager can refer patients, including those taking multiple medications or an anticoagulant, to a pharmacist for additional intervention and recommendations for medication consolidation.
The nurse also can help patients with long-term needs transition to other programs. In this high-risk population, many times, psychosocial issues send the patient back to the hospital, Kasoff said.
The collaborative plans to drill down to evaluate and learn what interventions might help those patients who still returned to the hospital. In addition, Montefiore plans to integrate some interventions into its standard of care so all patients could benefit from the results of the study.
“Its key for nurse executives to look at new practice models and the education and orientation of their staff and that they are knowledgeable regarding care transitions, based on the literature and outcomes of our study,” Kasoff said. “Its imperative that the nurses of today and of the future understand its not about episodic management of the patient in the hospital but more longitudinally, with a greater focus on population health management. Patients bouncing back and forth is not good from a quality, cost or patient satisfaction perspective.”
Debra Anscombe Wood, RN, is a freelance writer.