In an effort to cut down on costly, unnecessary hospital readmissions, the Granite Falls Hospital has worked with the Minnesota Hospital Association (MHA) to aid in the development and implementation of free patient programming to assist individuals in maintaining their prescribed health regimens as they transition from hospital to home.
“The goal of the Care Transitions Program (CTP) is to keep the hospital re-admissions limited,” said Registered Nurse (RN) and Care Transition Coach, Jodi Hempel. “So the goal is to empower clients, or patients, to know what their medications are and to keep them as independent at home as possible.”
According Granite Falls Hospital Director of Nursing Patty Massmann, the need for improved communication between patients, their families and referring agencies has been in existence since hospitals first started admitting people. Close examination of the Granite Falls hospital’s readmission rates of previous years confirmed this, indicating that the 11.5 percent of individuals who are readmitted into the hospital within 30-days typically fail to keep up with follow-up appointments and/or do not follow prescribed medication instructions.
In 2009 the Granite Falls Hospital took a proactive approach to address the issue by taking part in the Minnesota Hospital Association’s (MHA) Safe Transitions in Care Working Group, from which derived the Safe Transitions in Care Collaborative. As a member of the collaborative, Granite Falls Hospital developed a Travelling Care Plan, which it supplied to patients considered at-risk for readmission and who have a chronic health disease that requires long-term care. The plan consists of a three-ring binder that nurses prepare for patients to provide information about the management of their disease, their medication history and follow-up appointments.
Further involvement in Project RED (Re-engineered Discharge) and Project RARE (Reducing Avoidable Readmissions) would later lead to a two-day instructional course for Transition Care Collaborative members, allowing five Granite Falls Hospital nurses to be trained as Care Transition Coaches in 2011.
Over the past year and a half, the Granite Falls Hospital has been implementing CT programming with nurses trained as Care Transition Coaches through a Project RARE funded grant. As coaches, the nurses are responsible for introducing hospital patients to the program, providing an in-home visit and three follow-up phone calls.
RN and Care Transition Coach Helen Gunderson, said that a typical visit involves a lot of open ended questions (ie. When, how do you take this medication?) as the coaches work with patients to gain understanding and take responsibility for their own health care management. At no time do the coaches “show” the patients how to do something. It’s all about gentle, supportive guidance.
“A lot of clients know us as nurses and so we have to do quite a bit of explaining that it’s a new role we’re taking. But they’ve done well,” she said. “It’s all about keeping the patient in control of their own health. They learn more by doing for themselves than we ever could do for them. The hardest part for me was taking off the nurse hat and being a coach.”
Page 2 of 2 - Since its institution, Massmann said that the transition programming has been employed locally with 97 patients and, of those, a total of just three were re-admitted within 30 days. In comparison to previous data, this means that the re-admittance rate dropped from 11.5 percent without Transition Care Coaches to 3.1 percent––a trend echoed by the RARE Campaign statewide with an estimated 4,570 avoidable hospital readmissions prevented to the tune $40 million in savings in 2012.
With the recent sunset of the grant, there was the threat that these benefits may be lost but, instead, the Granite Falls Hospital Board has stepped up to the plate to ensure the program’s existence. Given the apparent impact of the coaches in holding down costs while empowering patients to stay in their homes, it’s easy to see why.