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 (SVMC'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
- 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.
How the program works
The Transitional Care Program helps patients with a chronic disease make the transition back to home by following up with them after discharge. These nurses check in with patients in the hospital, follow up soon after discharge, and may make a home visit.
In this program, nurses help patients:
- Create a beneficial routine
- Organize medications
- Understand what symptoms mean and how to relieve them
- 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.