Implementation of Transitional Care Program

Purpose:
Good Samaritan Hospital developed a Transitional Care Program (TCP) in 2013.The purpose of this department is to improve the quality and safety of patient care and reduce 30 day readmission rates. The target audience includes CHF, AMI, COPD, Pneumonia and Diabetes patients.

Significance:
In 2012, Medicare began penalizing hospitals with unacceptable readmission rates for the diagnoses of CHF, AMI and Pneumonia. The TCP will reduce readmissions and increase reimbursement for the hospital while improving patient's lifestyle through education and understanding of a chronic condition.

Strategy and Implementation:
The TCP provides weekly visits for up to twelve weeks after discharge regardless of ability to pay. Home visits are provided by RNs, trained to provide in-home education on disease process management, medication reconciliation, and systems review. Upon discovery of a decline in patient health status, the TC nurse will contact the patients' healthcare provider, report the problem, receive and implement orders in an attempt to improve patient's status. The initial TC nurse visit occurs while the patient is still in the hospital to establish rapport and begin education. The day after discharge, the TC nurse makes a home visit to complete medication reconciliation, perform a systems review, and continue patient education disease management. The TC patient is seen no less than weekly for the first four weeks. Weekly contact is maintained via home visit or telephone, for up to twelve weeks. A TC nurse is available to the patient anytime via pager.

Evaluation:
Success is and will be measured by decreased 30-day readmission rates for the target population.

Implications for Practice:
Practice implications include; lower medical costs, more efficient service delivery, decreased readmission rates and decreased utilization of the Emergency Department.