1. Care Transitions Program Sherrill Rhodes, MSN, HCAP Divisional Director Quality & Service Excellence Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health

2. Focus & Priorities  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

3. Inpatient Setting

4.  Transition Nurses across the facility  Modified LACE assessment tool  All “at risk” patients on designated units are followed until discharge  Coordination with social workers, utilization nurses, & charge nurses  All post-discharge needs are addressed including: home health, DME, medications, first MD appt, etc….  Follow up and Handoff

6. Community Setting

7. Community  3 Community Nurse Navigators  Focus on patient education, empowerment and connection with community resources  Make post discharge calls at 14,21, 30 days & PRN  Accept community & self referrals  Open referral process on the inpatient side

8. Resources Provided  Ongoing health education & promotion  Home visits (education & resource-focused, not home health or direct patient care)  Advocacy with providers  Assistance with various funding programs: FQHC, County, etc.  PPH grant-funded Ector County Health Care Coalition resources:  Medication assistance with discount programs  Transportation assistance/vouchers  Minor equipment for self-monitoring (BP cuffs, scales, glucometers)  Education materials

9. Outcomes Since program implementation: -over 1200 patients navigated on the outpatient side -ER visits reduced significantly in target population, readmission rate for population approximately 10-15% -All patients in program are set up with PCP for long-term management -Community partnerships established with FHQC-look alike, APS, local charity organizations, faith-based organizations Most common reason for readmission: -Noncompliance/lack of patient follow-up, inability to obtain medications, homeless population, alcoholism & drug use

10. PPH Grant Outcomes For the 18-month funded period (1/1/12-6/30/13): -13.9% reduction in hospitalizations for COPD/Asthma -24.5% reduction in hospitalizations for CHF -10.8% reduction in hospitalizations for all 9 adult PPH conditions combines -27.2% reduction in hospital charges to Medicaid -15.5% reduction in hospital charges to the Uninsured population

11. Future Plans  Transition nurse expansion into surgical service lines, critical care areas  Full expansion of navigation services into ER  Possible expansion of navigation services in maternal/child areas  Ongoing data collection & analysis

12. Questions