MDNews - Greater Boston

C A R E T R A N S ITI O N S M A N AG ER S M A K E IT WO R K KINDRED HEALTHCARE'S Care Transitions Program fosters patients' smooth progression from one healthcare setting to another, says Stacey Hodgman, MS, RN-BC, CMAC, Senior Director of Care Transitions with Kindred Healthcare. Hodgman has data to back up her assertion: She and her colleagues in Kindred's Care Transitions Program survey not only outcomes but also patients' attitudes about their outcomes, ascertaining that they're providing the best care for those patients. Communication is vital to the Care Transitions Program: communication with the primary care provider at every step, communication between settings at transition points, and communication with patients about their needs and goals. Nurse navigators known as care transitions managers oversee patients' progress. These patient advocates offer concierge-style services. They accompany patients home to examine medications in their cabinets, for example, or intervene with physicians whose care plans may not be fully aligned with patients' wishes. Equipped with iPads for viewing patients' electronic health records from each Kindred site, care transitions managers have extra insight into entire care trajectories. "Our Care Transitions Program adds value to our patients' experience," Hodgman says. "We build relationships and trust with each patient, and that has gone a long way toward improving satisfaction and outcomes." chronic obstructive pulmonary disease (COPD), renal failure, diabetes or pneu- monia. They often have some combination of these conditions. Additionally, stays in acute care hospitals may have left them confused, ventilator-dependent or physi- cally decompensated. They are typically taking multiple medications and have often had their medication list adjusted while in the acute setting. Acute care hospitals are well suited to providing lifesaving treatment; however, they are not designed to provide ongoing rehabilitative care over several weeks. Cardiologists, pulmonologists and other specialists who treat patients in acute care hospitals want to be confident that their charges will maintain and improve on gains made in the hospital as they transition into lower-intensity settings. Yet health care in the United States has at times managed these transitions less competently than should be the case, Dr. Kuvin says. According to the Agency for Healthcare Research and Quality (AHRQ), one in five patients with congestive heart failure returns to the hospital within 30 days of discharge; the same is true for patients with acute renal failure, COPD and pneumonia. So acute care hospitals are looking eagerly for ways to help patients transition successfully. At Kindred Healthcare, hospitals and physicians find an ideal partner. Offering staged care from transitional care hospitals through SNFs, assisted living and home health, Kindred facilitates improved patient outcomes that physicians can trust will endure. Throughout these transitions, two- way, consistent communication is key, Downey says. "Kindred physicians and nurses com- municate regularly with acute care hospital physicians," she says. "We include patients' specialty physicians in our weekly patient care conferences. For example, if we are caring for a patient who has had an organ transplant, we include the transplant surgeon in our calls and give both our on-site providers and the patient's family an opportunity to ask questions." Boston Integrated Market Care Transitions Managers (from left) Kim Ramos, RN, Christine Plante, RN, and Cathy Tracey, RN Stacey Hodgman, RN-BC, Senior Director of Care Transitions M D N E W S . CO M ■ MD NEWS Greater Boston | 7

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