Joni Hissong, director of case management, says it helps that the two staff transition care RNs are former home health nurses who know firsthand the issues that many patients face when they go home. "We have a saying that everyone looks the same in a hospital gown, but when you walk into their home, your eyes are opened to many opportunities," Hissong says. "As you assess the patient, you can see all of the things that you could maybe do for this patient to prevent that readmission. Maybe they don't have transportation back to their follow-up appointment. Maybe they really couldn't afford the
medication because they don't have prescription coverage."
Developing that early trust can even mean knowing such simple things as an accurate contact number, Johnson says. "The thing that I found fascinating is that when our transition care nurses were talking to patients and setting clear expectations of what the goal was and what they were going to do, often the patient or patient's family would say, 'Well, here, let me give you a phone number that really is our phone number.' So I think we're not perfect at it by any means, but we're beginning to establish that relationship so that the patient isn't just somebody at the end of the phone after they get home. The nurses know their problems, and they can speak to them on a very personal basis."
Jim Molpus is strategic relationships director for HealthLeaders Media. He may be contacted at firstname.lastname@example.org.
This article appears in the March 2013 issue of HealthLeaders magazine.