Easing the Transition From Hospital to Home
The NPs and other clinicians in the program have a conference call every week, during which they discuss their cases. The program has built up a network of key medical experts that the transitional care teams can tap into when they run into a challenge. “We’ve gotten this network of resource people together,” McCauley says, “so they have a support system.”
Eze’s home health agency is part of a health care co-op in Grand Junction, called Rocky Mountain Health Plans. As part of their daily responsibilities, designated staff from hospitals and home health agencies share notes about which patients are in the hospital and which are coming home soon. As a result, clinicians like Eze are at a patient’s bedside, working on the transition to home before the person has even left the hospital.
“That’s one big key here in Grand Junction,” she explains. “The moment they get hospitalized and it looks like they need home care, we try to target that patient and get services in place. That’s one good link right there, and it’s a very unique one.”
During his August visit to Grand Junction for a health reform town hall meeting, President Obama praised Eze’s community for keeping more people out of the hospital by providing excellent transitional care—and cutting costs in the process.
Stevens says the physicians who created the hospitalist program at St. Mary’s in Grand Junction put a special emphasis on communication and coordination of care. For example, they have a very thorough discharge plan for each patient and they get all of the caregivers together to talk with the patient and family before the person leaves the hospital. (For more on the hospitalist side of the story, see Hoppel AM. Hospitalists: ensuring quality care. Clinician Reviews. 2009;19[8]:cover, 36-38.)
The physicians who run the program care a lot about the community, Stevens says, so they set the right tone and expect a high standard of care. “They do the right thing for the patient, for the right reasons,” she adds.
GOALS AND ROLES
One of the important lessons McCauley and her colleagues teach nurses learning to provide transitional care is to tap into a patient’s goals to motivate them to make big lifestyle changes. “This is all about coaching and helping the patients to clarify their goals,” she says.
For example, McCauley remembers a heart failure patient who was very obese and had not left the second floor of her apartment for years. All it took was one important question from an NP: “What is your goal?” It turns out the woman had a strong desire to go to church. So the NP worked with her, setting up diet and exercise programs in her home and generally giving moral support. “She got her moving and that lady actually made it to church,” McCauley recalls triumphantly. “The whole thing was driven by the patient’s goals.”
Other times, aging patients will fiercely protect their privacy. McCauley remembers one nurse who got around this by knocking on the door and saying he was there to visit the lady’s dog. “He came in, made nice with the dog, and then did everything he needed for her,” McCauley recalls.
Clinicians working in transitional care also must spend more of their time working with family caregivers. For example, there was one case in which the patient had a well-meaning son—but the transitional care team soon discovered that he had a mental illness that prevented him from being a dependable caregiver. So they brought in other home care resources to make sure the patient was taking the correct medications.
Another part of the job is being a watchdog when insurance companies mandate patients’ discharges before they are ready. Eze has seen this before. “We’ll look at them and say we can’t accept them [for transitional care] because they are too unstable,” she says. “These are the sicker people they would never have sent out of the hospital 15 years ago.”
LONG-TERM IMPACT
Health reform experts such as Emory’s Thorpe predict transitional care will become more common across the country in the next few years, as long as health plans and hospitals are willing to pay for the extra staff required. Some of the current hot spots for transitional care include UPenn, Grand Junction, and the Care Transitions Program at the University of Colorado Medical School in Denver.
Policy analysts from AARP currently are pushing for a Medicare program that will cut reimbursement rates to hospitals that readmit patients within 30 days. Other bills requiring transitional care programs are pending in Congress and may even be folded into President Obama’s health reform plan.
