Transitional Care Management across the Continuum

Background/significance: Transitional care management (TCM) spans all healthcare settings. It begins on admission and extends along the continuum of care. Despite TCM efforts, gaps in patients’ healthcare still exist. Patients often voice feelings of exclusion from care-related decisions and frustration over lack of communication among their healthcare team. Incorporating telehealth into TCM places the patient at the center of their healthcare while increasing and improving communication among the patient’s healthcare team.

Objectives: Improve transitions of care across the care continuum using telehealth technology, as measured by admission length of stay and days between admissions.

Implementation: A multidisciplinary team approach was assembled to evaluate and improve upon the current care transition process. The team developed a warm handoff pilot which utilized secure technological capabilities upon discharge in an effort to bridge outpatient and inpatient care team communication. The warm handoff occurred at discharge from the inpatient setting. It involved the patient, inpatient nurse, and case manager utilizing secure telehealth technology via an iPad to communicate with the outpatient RN care navigator. The warm handoff lasted an average of 15 minutes and consisted of the inpatient nurse reviewing the after-visit summary including discharge instructions, medications, and upcoming follow-up appointments. The RN care navigator introduced themselves and informed the patient they would receive contact via telephone within 2 days of discharge to follow-up and ensure a safe transition home. The RN care navigator verified the patient’s contact information and educated the patient on whom to contact during business and after hours. The pilot ran 1 year.

Performance improvement outcome: Pre- and post-average length of stay (ALOS) and average days between admissions (ADBA) for 24 patients was tracked. Data showed that pre-ALOS was 5.65 days and post-ALOS was 3.8 days. Pre-ADBA was 48.8 and post-ABDA was 155.3. Feedback included patients expressing a greater confidence in their individual discharge plan and healthcare team. Care gaps such as medication errors, misunderstanding discharge instructions, and lack of awareness of outpatient follow-up appointments were reduced. Ambulatory RN care navigators also had greater success in reaching patients via telephone following discharge. This helped assess, identify, and address high-risk post-discharge needs. In addition, overall collaboration between the inpatient and outpatient setting increased.

Implications for nursing practice and/or future research: Incorporating and adjusting new technology into the workflow requires time and energy. Increased collaboration during the discharge process requires additional time and attention from inpatient staff that are already facing challenges in completing the discharge process in a timely manner. While implementation of this process is a work in progress, incorporating technological capabilities in an effort to enhance patient care has great benefits.