{ Care Transitions Program Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health Medical Center Health System.

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Presentation transcript:

{ Care Transitions Program Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health Medical Center Health System

 To improve the overall patient experience and continuum of care through risk-based screening and navigation services  To reduce avoidable readmissions and ER visits  Increase community resource utilization  Promote health & wellness in the community setting Focus & Priorities

 Transition Nurses  Modified LACE assessment tool  All “at risk” patients on designated units are followed until discharge  Coordination with social workers & case managers  All post-discharge needs are addressed including: home health, DME, medications, first MD appt, etc…. Inpatient Setting

 3 Nurse Navigators  Focus on patient education, empowerment and connection with community resources  Make post discharge calls at 14,21 & 30 days  Accept community & self referrals  Open referral process Community

 Medication assistance with discount programs  Transportation assistance/vouchers  Advocacy with providers  Home visits (education & resource-focused)  Minor equipment for self-monitoring (BP cuffs, scales, glucometers)  Ongoing health education & promotion  Assistance with various funding programs Resources Provided

 Since program implementation :  420 patients assisted  ER visits reduced significantly, readmission rate for population approximately 15-20%  Most common reason for readmission:  Alcoholism, noncompliance, homeless population Outcomes

*Coordinates outpatient care *Helps clients navigate the service systems *Develops a network of community resources *Provides avenues for prevention and education *Maintains program documentation and participates in ongoing program evaluation and reporting *Is notified of hospitalized member needs via the Navigator *Recruits congregational members into the Faith and Health Network *Shares community resources *Facilitates wellness activity participation *Is able to visit patient as a GUEST/VISITOR Navigator Liaison Roles Defined