care transitions program sherrill rhodes, msn, hcap divisional director quality & service...
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![Page 1: Care Transitions Program Sherrill Rhodes, MSN, HCAP Divisional Director Quality & Service Excellence Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population](https://reader035.vdocuments.us/reader035/viewer/2022070401/56649f1e5503460f94c351ae/html5/thumbnails/1.jpg)
Care Transitions Program
Sherrill Rhodes, MSN, HCAP
Divisional Director Quality & Service Excellence
Diana Ruiz, DNP, RN-BC, CWOCN, NE
Director of Population & Community Health
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Focus & Priorities
To improve the overall patient experience and continuum of care through “risk-based” screening and navigation servicesTo reduce avoidable readmissions and ER visitsIncrease community resource utilizationPromote health & wellness in the community setting
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Inpatient Setting
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Inpatient Setting Transition Nurses across the facility Modified LACE assessment tool All “at risk” patients on designated units are followed until dischargeCoordination with social workers, utilization nurses, & charge nursesAll post-discharge needs are addressed including: home health, DME, medications, first MD appt, etc…. Follow up and Handoff
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Community Setting
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Community 3 Community Nurse NavigatorsFocus on patient education, empowerment and connection with community resources Make post discharge calls at 14,21, 30 days & PRNAccept community & self referralsOpen referral process on the inpatient side
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Resources Provided Ongoing health education & promotion Home visits (education & resource-focused, not home health or direct patient care)Advocacy with providers Assistance with various funding programs: FQHC, County, etc. PPH grant-funded Ector County Health Care Coalition resources:
Medication assistance with discount programsTransportation assistance/vouchersMinor equipment for self-monitoring (BP cuffs, scales, glucometers)
Education materials
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Outcomes
Since program implementation:
-over 1200 patients navigated on the outpatient side
-ER visits reduced significantly in target population, readmission rate for population approximately 10-15%
-All patients in program are set up with PCP for long-term management
-Community partnerships established with FHQC-look alike, APS, local charity organizations, faith-based organizations
Most common reason for readmission:
-Noncompliance/lack of patient follow-up, inability to obtain medications, homeless population, alcoholism & drug use
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PPH Grant Outcomes For the 18-month funded period (1/1/12-6/30/13):
-13.9% reduction in hospitalizations for COPD/Asthma
-24.5% reduction in hospitalizations for CHF -10.8% reduction in hospitalizations for all 9
adult PPH conditions combines -27.2% reduction in hospital charges to Medicaid -15.5% reduction in hospital charges to the
Uninsured population
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Future PlansTransition nurse expansion into surgical service lines, critical care areas Full expansion of navigation services into ER Possible expansion of navigation services in maternal/child areas Ongoing data collection & analysis
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Questions