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3 Ways to Build a Strong Transitional Care Program

Analysis  |  By Jennifer Thew RN  
   November 08, 2016

When Southwestern Vermont Medical Center deployed its nurses in new ways, it saw a big drop in hospital admissions and ED usage among at-risk patients.

The American Nurses Credentialing Center last month awarded the 2016 National Magnet Nurse of the Year Award in Structural Empowerment to Barbara Richardson, MS, RN-BC, CCRN, clinical nurse specialist in transitional care nursing at Southwestern Vermont Medical Center in Bennington.

She earned the distinction for her transitional care nursing work.

The medical center serves a rural region in portions of three states, and began actively using transitional care nursing about three years ago. Since then, there has been a 69% decrease in hospital admissions and 29% drop in emergency department visits among patients enrolled in the program.

The patient cohort is traditionally hospitalized patients connected with primary care practices, Richardson says. "However, it can also be patients or people who have not been hospitalized but who the primary care providers feel are at risk for hospitalization or at risk for failing their medical regimen."


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The program, based on Mary Naylor's Transitional Care Model, was launched and led by Richardson and has grown in size from one clinical nurse specialist—Richardson—to one part-time and three full-time clinical nurse specialists as well as a social worker.

The program received a $200,000 innovation grant from the state of Vermont, which it used to add the part-time CNS as well as a health promotion advocate in the ED and some hours from a clinical pharmacist.

"When we first started, it was just transitional care nurses, and we quickly found that we had a community that was far more impoverished than we really recognized, and far less health-literate, with great social needs," Richardson says.

The program has a fluctuating patient load that is currently around 80 patients.

Richardson has the following advice for those who wish to build a successful transitional care nursing program:

1. Understand Your Community

When she was developing the program, Richardson considered a diagnosis-driven program model but realized that format would limit the reach of the program.

"We're a small community and we wouldn't be touching the numbers [of patients] we want to touch so we went a different direction," she says. "We'll see anyone with any diagnosis as long as they're a part of the primary care provider practices that we're associated with."


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Transitional care nurses do not see patients who have a primary behavioral health issue or drug addiction because these patients' needs are different than those of other transitional care patients.

2. Connect with Community Resources

Strong community partnerships have played a role in the success of the program, and Richardson fostered connections with community care partners, visiting nurses, and local nursing homes early in the program's development.

"We actually started connecting with them before we started seeing patients so that we would get to know what was out there in our community," she says.

She also created relationships with community resources like Meals on Wheels, food pantries, the Vermont Council for Independent Living, and the state's Support and Services at Home program.

"Our goal is to help people learn to take care of themselves," she says. "To teach them how to take care of themselves and provide them with tips and tools to really manage their chronic diseases on their own so that they don't have to come to the hospital to have them managed."

3. Shift Your Resources

When it comes to manpower, Richardson recommends looking at using existing resources in new ways. "You don't have to hire all sorts of new FTEs for a program like this," she says.

"We shifted resources from inpatient to outpatient. The clinical nurse specialist is a traditionally inpatient role and we were all [in inpatient roles]. Our inpatient census was going down and I think that's common in rural American in small community hospitals."

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.


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