It's important to equip patients who are returning to their own homes with skills to better "self-manage" their disease, especially if they are at high risk of being readmitted, White says.
That's where DMC's transition coaches, also called hospital-to-home nurses, come in. These individuals from community partnerships, employed and trained by the Detroit Area Agency on Aging, meet the patient in the hospital room when they first arrive and "are really important to helping them understand their disease," White says. "They help build a personal health record that the patient can take to their doctor's office" after they're home."
Using a modification based on Eric Coleman's Care Transitions Intervention coaching model, these coaches also visit patients in the home and help assess environmental issues that could result in them coming back to the hospital.
"Maybe the patient has transportation issues, or maybe there's no food or no heat. Maybe there aren't grab bars in the home, so they do fall risk assessments and depression screening, as well."
One of the best things about this program, White says, is that the same person visits the patient in the hospital and in the home for up to 30 days after discharge. "If the face at your door is someone you've spent time with at the hospital and have worked through a relationship together, that's going to be a comfortable moment to open that door and let that person in," White says. That's especially important in a city like Detroit, when safety among seniors is a concern.
Recently, a related program involving nurses in DMC's hospital-to-home program probably saved a patient's life, White says.
"We had one of our transition nurses appear at a patient's home the day after discharge. The durable medical equipment provider had already been there and hooked up the patient to home oxygen therapy, but it wasn't done the right way," she says.
"When our transition nurse arrived, the patient wasn't doing well. The nurse recognized the problem right away" and restored the patient's breathing. And then, the nurse prepared the patient's lunch.
"That probably avoided a readmission or worse," White says. "It's the kind of individual attention to their whole environment when they return home that's really critical to what I like to call a safe landing."
DMC is a Pioneer accountable care organization, and that has given the system clout to evaluate quality processes in area home health agencies, especially on measures like patient experience scores, cost, time to onset of services once they're referred, and whether the agency has an electronic medical record system.