Much is made of successful hand-offs between hospital departments, but a newly implemented program at Mercy Health-Fairfield Hospital in Fairfield, Ohio, is challenging nurses to think about another kind of hand-off: the one from hospital to home.
"At the time of discharge, we also need to manage that hand-off," says Teresa Riehle, RN, BSN, MBA, the hospital's director of Integrated Care Management.
To ease patients' transition to home and to prevent readmissions, Fairfield Hospital received a grant in November to participate in the Centers for Medicare & Medicaid Services Community-based Care Transitions project of the Partnership for Patients initiative. Now, Fairfield is a few weeks into a program that identifies Medicare patients who are a high risk for readmission. Those patients get assigned a care transition coach who helps them at home.
The coaches—some are RNs and some are social workers—work with the care coordination team at the hospital. The patients, who have two or more chronic conditions and are on multiple medications, are identified at discharge as being at high risk for readmission, and are then enrolled in the care transition program.
The coaches see the patients in the hospital, visit them at home a few days later, and follow up by phone at least three times over the next 30 days. Saying that the program "translates" a care plan for patients is probably a very accurate description.