Nobody likes to go to the emergency room or to need a hospital stay. Southwestern Vermont Medical Center’s Transitional Care Program and a $400,000 Vermont Health Care Innovation Project grant awarded to SVMC at the end of last month mean that more local patients will be able to improve management of chronic diseases and avoid hospitalization. The program calls upon the skills and experience of advanced practice nurses, who follow high-risk patients from primary care through their medical transitions.
“It’s really confusing for many patients to navigate their own way through the different care settings,” said Billie Lynn Allard, RN, administrative director of Outpatient Services and Education. “A Transitional Care Nurse improves patients’ and care providers’ access to the information they need.”
The program began when SVMC leaders asked, “How do we use our expert clinical nurses more effectively?” A literature search revealed the work of University of Pennsylvania’s Dr. Mary Naylor.
“Naylor’s research is 20 years old, but it is an idea whose time has come,” said Allard. “This is the crux of health care reform,” Allard said.
The hospital initiated the deployment of these acute-care resources to help patients in other settings.
“We recognized that the Transitional Care Program was a great idea with tremendous potential. We funded it. Now it is beginning to make a big impact for patients,” said Thomas Dee, SVHC’s president and CEO.
The Transitional Care Nurse team includes three seasoned clinical experts: Barbara Richardson, RN; Karen Coppin, RN; and Karen Hewson, RN. They trained at the University of Pennsylvania. Then, they partnered with primary care physicians offices to identify patients who could benefit from this assistance.
When one of these patients requires a hospital stay, the nurse sees them there and guides them through the experience. The nurse follows up with the patient soon after they are discharged—whether they go home, to a rehabilitation center or to a nursing home. The nurse helps them understand physicians’ discharge instructions, provides education on medication and reviews how to manage their symptoms.
The nurse checks in and communicates with the care providers, too. The primary care physician receives updates of what happened in the hospital, and the hospital staff receives better background information about the patient’s history.
And the program yields measureable results. The latest data compares the experiences of 101 patients 120 days before their first contact with the program and 120 days after. Emergency visits were reduced by 33 percent, and hospital visits went down by more than 68 percent.
Patients prefer not needing to use the emergency department and hospital as frequently. It improves their quality of life. Secondly, the program saves health care money.
Through the implementation of the program, the nurses have been able to see gaps in the system and recommend new standards. This helps all patients and reduces unnecessary costs. For instance, the program nurses have identified the need for more communication with pharmacists and social work organizations after patients return home. Improvements in these areas are already being made.
Over the next two years, the addition of grant funds will help the hospital hire the staff and conduct training needed to expand the program to more patients.
“Right now we are working with five primary care practices. With this grant, we are hoping to reach all of them,” Allard said.
Allard will present the program at the American Organization of Nurse Executives Conference in Phoenix in March. A conference to report results from the two years of grant-funded work is planned for 2017.
Anya Rader Wallack, chair of the Vermont Health Care Innovation Project, explained that the grant-supported projects will both reduce costs and improve care through unique community-based collaborations.
“We can learn from what these grantees do and improve quality and reduce costs for all Vermonters,” Wallack said.
SVMC is a full-service community hospital that is part of Southwestern Vermont Health Care (SVHC), an integrated health system serving Bennington and Windham Counties in Vermont and nearby communities in New York and Massachusetts. In addition to the hospital, SVHC consists of the Centers for Living and Rehabilitation, the VNA & Hospice of SVHC, the SVHC Foundation, and the SVMC Northshire and Deerfield Valley campuses. It also includes Dartmouth-Hitchcock Putnam Physicians, a multispecialty medical group operated in partnership with Dartmouth-Hitchcock.
Source: Southwestern Vermont Medical Center, Bennington 11.14.2014