Care Transitions Nurses Reduce Risk of Avoidable Hospital Readmissions

At Mercy Health in Cincinnati, nurses developed a system to evaluate patients and work collaboratively with other health care providers to provide them with the appropriate care. The team helps patients take ownership of their situations to help prevent readmissions.
At Mercy Health in Cincinnati, nurses developed a system to evaluate patients and work collaboratively with other health care providers to provide them with the appropriate care. The team helps patients take ownership of their situations to help prevent readmissions.

At Mercy Health in Cincinnati, nurses developed a system to evaluate patients and work collaboratively with other health care providers to provide them with the appropriate care. The team helps patients take ownership of their situations to help prevent readmissions.

Title:
Care Transitions Nurses Improve Continuity of Care During and After Discharge

Results:
In the first ten months of 2012, Mercy Health saw its all-cause readmission rates for heart failure, AMI, and pneumonia drop by 15 percent. Furthermore, 61percent of the patients seen by a care transitions nurse saw their primary care physician within seven days of their transition from the hospital to home. The estimated savings from the avoided readmissions was approximately $495,000.

Profile:
Mercy Health features a staff of 9,000 employees and is affiliated with more than 1,800 physicians who represent a wide array of medical and surgical specialties, practicing in more than 100 network locations throughout Cincinnati.

Contacts:
Molly Sergent
Communications Specialist
Mercy Health
513-981-6316
msergent@health-partners.org

Nanette Bentley
Director, Public Relations
Mercy Health
513-981-6308
nbentley@health-partners.org

Innovation Implementation:
Mercy Health in Cincinnati, Ohio implemented Dr. Eric Coleman’s care transitions model by using nurses specially trained to act as patients’ guides through the discharge process. Once the patient is discharged, the nurse provides follow-up care built on the four pillars of the Coleman model.

The transition nurse meets with the patient to discuss why he or she has been admitted to get an understanding of the patient’s condition and how it was managed leading up to their hospitalization. While the patient is still in the hospital, the nurse begins to lay the groundwork that will lead to a successful care transition.

Once the patient returns home, he stays in regular communication with the nurse until capable of managing his condition on his own, or with the help of a family member. The process begins with a home visit within two to three days of discharge. During the visit the transitions nurse goes over the patient’s medications, making sure he has the necessary prescriptions filled and understands the dosages and when to take them.

Together, the nurse and patient create a dynamic patient-centered medical record. This helps the patient understand her condition. The medical record also puts all of her relevant medical information in one easy-to-access place, ensuring that when she seeks care her provider will be fully informed.

The hospital has found that a key to the program’s success is the nurse making sure that necessary follow-up trips to the patient’s primary care doctor are scheduled, and that the patient is able to get to the appointments. This is important, because the hospital has found that transportation is often an obstacle for patient populations vulnerable to avoidable readmissions.

In the first ten months of 2012, Mercy Health saw its all-cause readmission rates for heart failure, AMI, and pneumonia drop by 15 percent. Furthermore, 61percent of the patients seen by a care transitions nurse saw their primary care physician within seven days of their transition from the hospital to home. The estimated savings from the avoided readmissions was approximately $495,000.