The challenges for patients who have chronic illnesses and multiple complications don’t end when they leave the hospital. Health, social and financial issues can complicate their recovery, and they often end up back in the hospital.
To improve patient outcomes and decrease hospital re-admissions, Emory University Hospital and Emory University Hospital Midtown are extending care beyond their walls.
“Many hospitals are establishing programs to help hospital patients make a safer and more successful transition home,” said Napth’tali B. Edge, director of Emory Healthcare’s transition manager program. “What makes our transition management program unique is that it’s nurse-practitioner driven.”
The two hospitals have 11 nurse practitioners who serve as transition managers. They work with high-risk patients across six service lines, including hospital medicine, general surgery, nephrology, heart failure/cardiology, urology/gynecology and oncology.
“We borrowed ideas from the transition care models of Mary D. Naylor and Dr. Eric Coleman, both of whom have done extensive research in the field. But knowing our patients and their needs, we designed our own program,” said Edge, BSN, RN, MSN, FNP, MBA. “We chose to serve all at-risk patients — not just seniors — because risk can be present at any age. Young people sometimes think they’re invincible and don’t need to take their medications after they go home.”
Nurse practitioners were chosen as the optimum transition managers because of their education and experience. “They have greater autonomy and scope of practice,” Edge said.
They’re familiar with evidence-based practice and are accustomed to working collaboratively with other providers. They also understand the financial implications of substandard care.
“When hospital patients are being discharged, they’re so ready to go home that they don’t listen carefully to their discharge instructions,” said Elizabeth Bolton-Harris, MSN, APRN-BC, transition manager at Emory University Hospital Midtown. “When they get home, they may not remember how to take their medicine or that they had a follow-up doctor’s appointment. They aren’t going to tell the discharge nurse that they can’t afford their prescription or don’t know how to call and set up home health visits for wound care.”
Bolton-Harris begins preparing her patients for post-hospital recovery while they’re still in the hospital. She visits them, learns about their illnesses and assesses the likelihood risk of having a successful outcome at home so she can help hospital staff and doctors make appropriate discharge decisions.
Once patients go home, transition managers follow up by phone within 24 hours and as often as needed for the next 30 days. They answer questions, address issues, schedule doctor’s appointments, go over medications to reduce errors, gather records and make sure patients have access to the services they need. By asking the right questions, a transition manager can focus on what is needed, whether it’s reinforcing diet restrictions or explaining what a person needs to know about his or her disease.
Bolton-Harris enjoys her new role. “When I was a nurse practitioner managing patients in the hospital, I rarely got involved in post-discharge care. I like being able to establish a relationship with my patients and help to provide exactly what they need,” she said.
For example, a patient who had been on 10 medications didn’t know which of them to continue taking after surgery. Bolton-Harris had the man read the labels on the bottles and she helped him sort it out.
“My goal is to educate and empower patients so that they can better manage their own illnesses, be healthier and be better consumers of health care,” she said.
Patients and their families have grown to appreciate the 15-month-old program. With a single phone call, they can call one person who answers questions or get help navigating follow-up visits or therapies.
“We’ve become the glue that holds everything together so that the patient gets consistent care,” Bolton-Harris said. “We’re filling in a lot of gaps.”
Some service lines have already shown improvement in getting patients home as safely and quickly as possible. Happier and healthier patients is the ultimate goal.
“We’re measuring our success in terms of patient satisfaction, length of stays, re-admission rates and the overall health status of our patients,” Edge said. “We believe that we have a very strong transition model of care, and we’re proud of it. Our results are showing that we’re making an impact.”
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