What We Tried

We implemented a transitional care program that is free of charge and voluntary for patients. We began with two part-time nurses, and provided services seven days a week. We now have one full-time nurse and one part-time nurse, as well as a supplemental nurse.  We meet patients during their hospital stays and follow up within 48 hours of discharge with home visits. The visits consist of medication reconciliation and management, ensuring a follow-up appointment with their doctor(s), providing an up-to-date medication list and personal health record and educating them on disease process. We also offer support during physician appointments. Heart failure patients without scales are provided one. The standard approach is weekly visits for four weeks, and then weekly phone calls for four weeks. That approach is tailored to the individual needs of the patient. When appropriate, we also assist them with obtaining needed resources, including homemaker services, equipment, delivered meals and packaged medications.

We review the census daily, and we have criteria we use to determine who would benefit from our program. We prioritize patients in three tiers: 1. Acute CHF, Pneumonia and/or COPD. 2. Admitted for an unrelated problem but has a history of CHF and/or COPD and has been hospitalized within the last year. 3. Admitted for an unrelated problem but has a history of CHF and/or COPD and has not been hospitalized within the last year. We see the acute patients first. Our criteria excludes some patients, as the research has shown they don’t benefit from this type of program for various reasons: skilled nursing residents and assisted living residents (their environments are controlled), acute psychiatric diagnosis, terminal or hospice patients, patients actively receiving cancer care/chemo, non-English speaking patients (unless they have family members/caregivers we can teach).

Post-enrollment (about 60 days), we have hopefully taught patients the skills they need to manage on their own. They also have our contact number should they need anything in the future, and we always tell them we are a resource for them. We have had many patients call us later for things like medication changes, trouble getting appointments, medical advice/questions and to have the care team visit them to help manage a change in diagnosis or medications.