Transcript Care Transitions Program - Texas Regional Healthcare

Care Transitions Program
Diana Ruiz, DNP, RN-BC, CWOCN, NE
Director of Population & Community Health
Medical Center Health System
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Focus & Priorities
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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
Inpatient Setting
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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….
Community
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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
Resources Provided
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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
Outcomes
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Since program implementation:
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420 patients assisted
ER visits reduced significantly, readmission
rate for population approximately 15-20%
Most common reason for readmission:
Alcoholism, noncompliance, homeless
population
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Roles Defined
Navigator
*Coordinates outpatient care
*Helps clients navigate the service
systems
Liaison
*Is notified of hospitalized member
needs via the Navigator
*Recruits congregational members into
the Faith and Health Network
*Develops a network of community
resources
*Shares community resources
*Provides avenues for prevention and
education
*Facilitates wellness activity
participation
*Maintains program documentation and
participates in ongoing program
evaluation and reporting
*Is able to visit patient as a
GUEST/VISITOR