Transitional Care

For some people, having a chronic disease means frequent trips to the hospital. Bouncing between home, the emergency room, and an inpatient bed is disruptive at best. It’s also an indication that the disease isn’t well controlled. So, Southwestern Vermont Medical Center’s clinical leaders looked for a way to prevent this cycle.

They found that small problems often lead patients back to the hospital: taking medication incorrectly, misunderstanding how to use medical equipment, or not recognizing early warning signs. Their research also showed that some extra attention might help.

“We found that having a guide can help patients and doctors understand and prevent a recurring problem,” said Billie Lynn Allard, RN, administrative director of Outpatient Services and Education. SVMC created a team of three experienced nurses to act as guides and to partner with area primary care offices. These nurses identify patients with a chronic disease who could use extra help transitioning from hospital to home. Appropriately, the program is called the Transitional Care Program.

These nurses check in with patients in the hospital, follow up soon after discharge, and may make a home visit. The nurses help patients create a beneficial routine, organize medications, and understand what symptoms mean and how to relieve them. They also work to create a communication bridge between the hospital and primary care doctors, so each has better information about the patient’s history.

The program is working too. When compared with similar patients not in the program, participants had 33 percent fewer emergency visits and 68 percent fewer hospital stays. In 2014, the program earned a $400,000 grant from the Vermont Health Care Innovation Project to expand. The nurses hope to forge partnerships with each of the ten primary care offices in the area. Soon, more patients will benefit from having an experienced guide.