Transitional care giving hospital patients lifeline long after discharge

February 26, 2016 06:37 PM

BENNINGTON, Vt. - Improving the patient experience and their health while reducing costs are the tenants of health care reform.

Southwestern Vermont Medical Center in Bennington is accomplishing that by embracing a growing national movement.

It's called transitional nursing care.

Henry Campbell, 72, was hit by a car last summer.

He needs a little help in these last stages of recovery and that's where Karen Coppin literally comes in.

As part of the Transitional Care team at Southwestern Vermont Medical Center she makes house calls.

“I would say on average we see three patients a day,” Coppin noted.

Transitional care nurses provide support through home visits or simply checking in by phone with patients after they're discharged from the hospital.

Often, like Campbell, they're confused by all their medications.

“So I went with Henry to one of his visits so that talk with his doctor about it a little bit more, but I thought it would be better for Henry to have all his medications prepackaged,” explained Coppin.

People are identified for care by their primary care doctor, hospital staff or nursing home staff at the Center for Living and Rehab.

“We've had patients that are in their 30s and we've had patients that are 101,” pointed out Billie Lynn Allard.

She developed the program about two years ago in response to health care reform which mandates shorter hospital stays.   

However, shorter stays can mean little time for patients to understand their discharge instruction. That can get in the way of another mandate to reduce readmission rates.

Transitional care helps on both counts.

Knowing they have a lifeline, patients return home feeling more secure and less anxious about their recovery.

“We like to stop the care after three months. It doesn't always happen. Sometimes we let them be on their own and then the primary care doctor will say they need your help again,” admitted Allard.

The program started with one nurse. Now there are four nurses.

Thanks to a $400,000 grant from the Vermont Healthcare Innovation Project, a social worker, respiratory therapist, four pharmacists along with health educators have been added, and it's working.  

“We have been able to very, very specifically decrease readmission in the population of patients who belong to the program. We've also been able to decrease the number of emergency department visits,” added Carol Conroy, DNP, the vice president of operations at Southwestern Vermont Medical Center.

More than 400 patients have been served since the program began, at no cost to them.

Southwestern Vermont Medical Center now plans to create a tool box for other hospitals to use.


Benita Zahn

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