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Care Transitions Program

Diana Ruiz, DNP, RN-BC, CWOCN, NEDirector of Population & Community Health

Medical Center Health System

To improve the overall patient experience and continuum of care through risk-based screening and navigation services

To reduce avoidable readmissions and ER visits

Increase community resource utilization Promote health & wellness in the

community setting

Focus & Priorities

Transition Nurses Modified LACE assessment tool All “at risk” patients on designated units

are followed until discharge Coordination with social workers & case

managers All post-discharge needs are addressed

including: home health, DME, medications, first MD appt, etc….

Inpatient Setting

3 Nurse Navigators Focus on patient education,

empowerment and connection with community resources

Make post discharge calls at 14,21 & 30 days

Accept community & self referrals Open referral process

Community

Medication assistance with discount programs

Transportation assistance/vouchers Advocacy with providers Home visits (education & resource-

focused) Minor equipment for self-monitoring (BP

cuffs, scales, glucometers) Ongoing health education & promotion Assistance with various funding

programs

Resources Provided

Since program implementation: 420 patients assisted ER visits reduced significantly,

readmission rate for population approximately 15-20%

Most common reason for readmission:

Alcoholism, noncompliance, homeless population

Outcomes

*Coordinates outpatient care

*Helps clients navigate the service systems

*Develops a network of community resources

*Provides avenues for prevention and education

*Maintains program documentation and participates in ongoing program evaluation and reporting

*Is notified of hospitalized member needs via the Navigator

*Recruits congregational members into the Faith and Health Network

*Shares community resources

*Facilitates wellness activity participation

*Is able to visit patient as a GUEST/VISITOR

Navigator

Liaison

Roles Defined