Easing the Transition From Hospital to Home

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On a recent day, a team of nurse practitioners from the University of Pennsylvania (UPenn) School of Nursing stopped by to visit an 80-year-old patient. She had just been discharged from the hospital, with a sheaf of prescriptions in her hand.

While visiting the patient in her home, less than 24 hours after discharge, the NPs discovered the woman had filled all but one of her prescriptions. Apparently, the pharmacy had told the woman that her insurance would not cover that medication.

So she simply didn’t fill it, even though it was an important pain medication that would ease her recovery. The NPs called the woman’s doctor and agreed on a different pain medication that would be covered, and the woman started taking it right away.

“Had we not been there, this lady would have taken most of her pills, but not this one,” says Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA, an associate dean at UPenn. “She would have sat home, and her symptoms would have gotten worse and worse until she had to return to the hospital.”

McCauley and the NPs are part of a long-term research project at UPenn, which focuses on keeping elderly patients out of the hospital. The concept is known as transitional care, and it has become an important part of President Obama’s health care reform plan. Prevention of hospital readmissions among Medicare patients alone could save nearly $20 billion per year, according to estimates recently published in the New England Journal of Medicine.

“Any change a patient makes—from a physician’s office to home, or from the hospital to a nursing home—those are all transitions, and those transitions don’t go very well,” says Kenneth Thorpe, PhD, chair of the Health Policy and Management Department at Emory University’s Rollins School of Public Health. “In fact, 20% of Medicare patients are readmitted within 30 days.”

Thorpe, who has been advising Washington lawmakers on ways to cut health care costs, estimates that communities could cut readmissions at least in half and save billions of dollars if they put transitional care teams, such as the UPenn group, in place.

Besides helping the local and national economy, transitional care teams can make a difference on a more personal level. Patients and families must deal with so many complex drugs and devices, from blood glucose monitors to oxygen machines and nebulizers that “it becomes a full-time job,” says Chileen Eze, BS, RN, who works for Rocky Mountain Home Health in Grand Junction, Colorado. “And they just don’t have the energy to do it, because they feel terrible.”

NPs and PAs will play a key role as this type of care comes to the forefront, experts predict, because they are team players with excellent communication skills and a broad knowledge base. “A big part of what the clinician has to do is go negotiate with the health care system on behalf of the patient,” McCauley says. “It takes tremendous sophistication and people skills.”

Mary Lou Stevens, PA-C, a hospitalist at St. Mary’s Hospital in Grand Junction, Colorado, loves her work, helping patients move successfully from hospital to home (or to a nursing home or hospice facility). “It’s a wonderful job,” she says. “It’s intellectually challenging, and I do think it’s a very good fit for a PA.”

Stevens says PAs are generally good at communicating and navigating the health care system on behalf of patients—basically seeing the big picture. In her case, Stevens became a PA after 25 years in nursing (primarily in oncology). “In this job, you are professionally growing all the time,” she says. “And it’s very satisfying.”

McCauley and her colleagues have been studying the “Naylor model” of transitional care—named for Mary Naylor, PhD, FAAN, RN, Director of UPenn’s New Courtland Center for Transitions and Health—in large clinical trials for 15 years. Now, they are sending advanced practice nurses and clinical nurse specialists out into the field to test the system in the real world. They are working through large existing health plans, such as Kaiser Permanente in California.

Most of the advanced practice nurses in the program have a strong background in acute care, home care, or both. Others have a specialty in gerontology.

Their first step is to study a series of online training modules, so they can brush up on diabetes, for example, or heart failure. “Next, we pair them with experienced transitional care nurses and key physicians who understand the model,” McCauley explains. “Over time, we gradually get them to be more and more independent.”

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