Much is made of successful hand-offs between hospital departments, but a newly implemented program at Mercy Health-Fairfield Hospital in Fairfield, Ohio, is challenging nurses to think about another kind of hand-off: the one from hospital to home.
"At the time of discharge, we also need to manage that hand-off," says Teresa Riehle, RN, BSN, MBA, the hospital's director of Integrated Care Management.
To ease patients' transition to home and to prevent readmissions, Fairfield Hospital received a grant in November to participate in the Centers for Medicare & Medicaid Services Community-based Care Transitions project of the Partnership for Patients initiative. Now, Fairfield is a few weeks into a program that identifies Medicare patients who are a high risk for readmission. Those patients get assigned a care transition coach who helps them at home.
The coaches—some are RNs and some are social workers—work with the care coordination team at the hospital. The patients, who have two or more chronic conditions and are on multiple medications, are identified at discharge as being at high risk for readmission, and are then enrolled in the care transition program.
The coaches see the patients in the hospital, visit them at home a few days later, and follow up by phone at least three times over the next 30 days. Saying that the program "translates" a care plan for patients is probably a very accurate description.
"I think we in acute care don't speak the same language as a patient at home trying to take their medications," Riehle tells HealthLeaders Media. "We don't even call them the same things."
According to Riehle, the coaches help set up patient-specific programs for successfully caring for themselves at home, teaching them everything they need to know, from taking their medications correctly to helping them make follow-up appointments. They also teach patients how to monitor their own symptoms and solve problems based on what they're experiencing.
"Whatever their condition is, [they learn] the top things that they need to be looking for that they need to call their doctor about," Riehle says.
She adds that in addition to preventing readmissions, the program aims to teach patients to be proactive in their own healthcare, helping them do things for themselves.
"At the end of that 30 days, the patient is better able to manage their own healthcare," she says.
So far, so good.
"It's going really well," Riehle says of Fairfield's program. "Our coach did 10 home visits the first week she was here."
Although Fairfield Hospital is only a few weeks into its program, Riehle says that the pilot program that their grant was based on decreased the readmission rate for the target population to 7.5%, which is about a third of the national rate.
Also, she says nurses have already learned a lot about the challenges patients face at home.
"I think the thing that surprises them the most is how confused patients really are about their medications," Riehle says.
The focus on readmissions has also broadened nurses' view of healthcare.
"In acute care, we always lived in our own little world….and we really have to think about managing that patient across the whole continuum," Riehle says, "so they don't just bounce right back to us."
That broadened view of healthcare puts the patient in a larger context than just their hospital stay. Riehle says it also requires partnerships between a wide range of stakeholders in the larger community.
"I think we're going to have to really think about ‘how do we manage those relationships?" Riehle says.
Or, put a different way: "How do we do a good hand-off?"
Alexandra Wilson Pecci is an editor for HealthLeaders.
