Transitions Navigator and Hospital Readmissions

Transition Navigator Program

Transition Navigator Program

Transition Navigator Program

The Transition Navigator communicates with the hospital and primary care teams to bridge the gap and ensure continuity of care. They work closely with patients to make certain they have a clear understanding of their plan and provide additional support through a personal care manager.
The Transition Navigator communicates with the hospital and primary care teams to bridge the gap and ensure continuity of care. They work closely with patients to make certain they have a clear understanding of their plan and provide additional support through a personal care manager.

Transition Navigator Program

The Transition Navigator communicates with the hospital and primary care teams to bridge the gap and ensure continuity of care. They work closely with patients to make certain they have a clear understanding of their plan and provide additional support through a personal care manager.

Title:
The Contribution of a Hospital-Based, Medical Home-Connected Navigator to Risk of Readmission

Result:
The 30-day readmission rate for patients who received transitions navigator services between July 2012 and September 2012 was 23 percent less than the hospital’s overall 30-day readmission rate (11.5% versus 15%). These data have not yet been adjusted for age or number of comorbidities and do not include readmissions to hospitals other than the University of Utah.  Additional data analysis is needed to adjust for confounders and to include readmissions to other hospitals.

Institution:
University of Utah Health Care
Community Clinics
50 North Medical Drive
Salt Lake City, Utah 84132

Profile:
The University of Utah Health Care Community Clinics are a network of 10 neighborhood health centers that offer primary care and specialty services to members of most insurance plans and fee-for-service clients.

Contact:
Stephanie Wallace, RN
Transition Navigator
University of Utah Health Care
Community Clinics
stephanie.wallace@hsc.utah.edu

Innovation Implementation:
Responding to newly emerging models of coordinated care, staff at University of Utah Health Care piloted hiring a transitions navigator, leveraging best practices from national care transitions leaders. The transitions navigator is embedded within the University of Utah Hospital inpatient care teams and the outpatient local primary care network to ensure that critical factors necessary for safe care transitions are not overlooked as patients’ location of care shifts from the hospital back to their medical home.

The University of Utah team developed a set of questions based on best practices in care transitions for the transition navigator to ask patients and their family members.  These questions ensured patients  understood critical information about their care, including who they identified as their primary physician, who to call in a crisis, and their knowledge of changes to their medication regimen. For those patients found to have barriers in accessing or affording their medications, the transitions navigator leveraged available community resources to overcome these barriers.

The transitions navigator coordinated any needed outpatient care, including pending labs and imaging studies, and immediately followed up with patients’ primary care providers to relay updated problem lists and treatment plans.  The transitions navigator also coordinated closely with care managers deployed within each Community Clinic who supported the primary care providers in addressing the essential aspects of care coordination before, during and after the time of discharge. Preliminary unadjusted data involving only the University of Utah Hospital show the transitions navigator pilot program, along with other components of University of Utah Health Care’s Transitions Management program, have reduced readmission rates by 23 percent.

 

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