Handling the Handoff: The Key to Care Transitions

Judy Rich, President & CEO, Tucson Medical CenterIn this guest post, Judy Rich, president and CEO of Tucson Medical Center, shares the innovative ways her teams are leveraging technology to support improvements in care transitions. Tucson Medical Center is also part of Arizona Connected Care, which was recently selected to participate in the Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organization (ACO), sponsored by the Centers for Medicare and Medicaid Services (CMS).

Every hospital executive and clinician today is working to effectively manage what we call the “white space” – the place where patients exist between episodes of care, after a doctor’s appointment, surgery or procedure and before their next touch point or follow up. While it’s challenging to connect with patients once they leave the hospital and are out of our control, doing so is critical to both increasing quality of care and controlling healthcare costs. Mastering the “white space” plays a key role in helping patients stay on the road to recovery and ultimately reduce hospital readmissions.

Tucson Medical CenterAt Tucson Medical Center, we’re spending more time on readmission prevention than ever before. While the goals we’ve set for our health system around care transitions are only made possible with the help of the right technology, I have a nursing background and know there are many other factors to consider. Leveraging electronic medical records that enable clinicians to easily access specific patient histories and care pathways at the moment it matters, as well as reveal critical data about the broader patient community, is just the tip of the iceberg in terms of what technology can do for us. But we still need a range of caregivers and clinicians to engage and connect with patients directly – whether by reinforcing what we’ve told them during hospitalization with clear instructions or by following up with patients after they leave to ensure they’re taking their medications and following care protocols properly. Here are a few examples of where we’ve combined the best of both worlds – technology and clinical – to improve care transitions:

  • Access to Nurses After Discharge – Patients can reach nurses live via phone for guidance even after they’ve left our facilities, which we’ve found helps them avoid making another trip to the hospital. This service is especially critical for elderly patients who might not have consistent access to transportation. Even more importantly, this needs to be a “warm call” – one with someone who can quickly access the patient’s specific history so that the patient doesn’t feels the person on the line is remote and disconnected. The coordination between the hospital care management team and the Arizona Connected Care transition nurses provides the patient with a seamless and continuous resource to reach out to until they are stable and back in the care of their primary care physician.
  • Put me in, Coach – Our system assigns each patient a transition nurse or “coach” who visits them in the hospital, conducts a home visit within three days of discharge and follows up via phone at regular intervals. The coach is responsible for answering questions, reviewing medications and identifying any red flags with patients that may cause a relapse or issue that sends them back into the hospital.  They have access to the provider’s EMR and communicate closely with them, while still making sure the patient is empowered to communicate directly with their primary care physician.
  • Home is where the help is – The Hospital to Home (H2H) model, in collaboration with our outpatient care advocacy, is designed for mostly elderly patients with chronic conditions (CPOD, diabetes, Parkinson’s, Alzheimer’s) who are facing a number of life restrictions due to their illnesses. The team in this instance provides ongoing emotional and physical support, including screening for depression, educating patients on ways they can improve their quality of life and engaging with pharmacists and dieticians, etc.  By bringing resources to the home, they offer alternatives to ED visits and help prevent unnecessary hospitalizations.

Regardless of the model, nurses and caregivers providing transition support across Tucson Medical Center have gone through very specific training to be able to provide this type of intensive, case-based and interactive care. With more of a focus on the patient’s health and success outside of hospital walls, health systems can keep both quality outcomes and costs on track.

— Judy Rich, president and CEO of Tucson Medical Center

Judy Rich was recently featured in Becker’s Hospital Review discussing her “Top 5 Tips for Embracing Accountable Care.”

One thought on “Handling the Handoff: The Key to Care Transitions

  1. I agree with the above. We are setting up a Health Transition program just like the above. We are just rolling it out in our organization. It will improve patient satisfaction, outcomes and prevent rehospitalizations.

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