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and Kindred's transitional care and rehabilitation center at the Greens (in Lyndhurst). "As a group, the Kindred facilities and supporting hospitals have the potential to perform better collectively than independently," Dr. Felver explains. The ability to improve cross-referral admission patterns and increase participation in cross-divisional education is also greater. But the main focus of the Transitional Care Program is helping patients navigate seamlessly and successfully through the post-acute continuum. This is done by + determining and managing a patient's/caregiver's transitional needs + implementing transitional planning tools + facilitating the safe transition of patients from one level of care or provider to another through effective interventions + sharing accountability across providers and organizations, and + providing supportive resources and services. "First we identify patients with high risk factors," says Janis Faehnrich, MSN, MBA, Senior Director of Care Management for Kindred's Cleveland Integrated Care Market. High risk factors include chronic heart failure, chronic obstructive pulmonary disease, pneumonia, sepsis, and hip fractures or other conditions causing mobility problems. Patients who live alone or are taking multiple medications, those who have issues with healthcare literacy, and those who do not speak or understand English are also considered to be high risk. "Once we've identified the patient's high risk factors, we help plan and provide appropriate interventions," she says. "This is done even before the patient is transferred from the acute care hospital to one of our facilities, and then again each time the patient moves to another level of care and then back into the home, to ensure smooth transitions and optimal outcomes." Nurses trained as transitional care managers are involved from beginning to end, coordinating health care from one setting to another. One of their primary responsibilities is communication with patients' primary care physicians to ensure they are involved every step of the way. Transitional care managers are also charged with educating and teaching the patient and/or caregiver to better understand their disease and manage it. "Our transitional care managers are nurses with experience across the full continuum of care along with knowledge of home care," Faehnrich says. "They meet with the interdisciplinary team and with the patient and his/her family, they communicate with the patient's primary care physician (because that's an area that's often neglected), they help educate the patient and the family about disease management and self-management, and then they follow the patient as he/she moves from facility to facility or back into their own home." Once the patient is close to going home, the transitional care manager makes arrangements to ensure medications and durable medical equipment is there, and that the patient has an appointment with and transportation to his/her primary care physician's office. The transitional care manager also develops a personal health record for the patient to take to this appointment. It includes lists of medications the patient is taking and has taken, details of his/her medical condition including any allergies, and key individuals to contact in the community. "We just want to ensure a successful transition of patients back to their primary care physicians," says Dr. Felver. "And that's something that the transitional care manager discusses frequently with the patient and his/her caregiver – the importance of going back to the primary care physician, going to appointments, when to call the doctor versus when to go to the ED. We do everything we can do to make sure the patient doesn't end up back in the hospital." "Kindred really wants to be at the forefront of healthcare reform by putting initiatives, like our Transitional Care Program, in place," explains Faehnrich "The ultimate goal," Dr. Felver emphasizes, "is to improve clinical outcomes and patient satisfaction while reducing readmission rates." For more information about Kindred Healthcare in Cleveland, visit www.kindred.com. To refer a patient, call 216-983-8011. ■ Janis Faehnrich, mSN, mba, is Senior Director of Care management for kindred's Cleveland integrated Care market. NovEmBEr /dECEmBEr ■ mdNEWS.Com ■ MD News Cleveland/Akron/Canton | 29