Nash Health Care Systems – Nash Health Care Transitional Care Program

Overview

The Nash Health Care Transitional Care Program (TCP) serves as a model of the organizational mission to provide superior quality health care services to help improve the health of the community in a caring, efficient, and financially sound manner. The TCP encompasses evidence-based strategies between the health care system and its community care partners through emphasis on a unified direction for managing complex patient populations, alignment of key personnel and resources, and a commitment to quality improvement. The TCP was initiated in 2011 as a pilot program to address high-risk patients that were admitted for heart failure. The demonstration was a regional partnership project; partners included Community Care Plan of Eastern Carolina – Access East, NHCS, Vidant Edgecombe Hospital, Wilson Medical Center, Halifax Regional Medical Center, and the Upper Coastal Plains Council of Governments Area Agency on Aging.

Impact

In its original form, the TCP maintained on average about 50 patients per month in the Heart Failure follow-up program. Since participation in the Medicare demonstration, Nash Health Care has contacted 3,599 patients in the post-discharge period from 2013 to date. The intervention includes one in-home visit and/or physician office visit with the patient followed by four telephone calls weekly over the course of 30 days. Patients are followed not only in the home setting, but also in Nash’s acute rehabilitation facility and several area short-term rehabilitation facilities. Results demonstrate a significant reduction in readmissions for clients who are receiving the care transition intervention versus those clients that are not in program.

Lessons Learned

The primary lessons learned in developing these initiatives are that there needs to be a medium for ongoing communication and cross-continuum collaboration; risk stratification assists in identifying patients to promote tailored interventions based on risk level; emphasis should be placed on gap analysis before developing additional programs (who needs to be involved from start to finish); operations should be based on data-driven results in developing each new small tests of change; and discussions for sustainability beyond grant-funded initiatives should occur to ensure appropriate measurement of outcomes to support sustainability.

Future Goals

Expand follow-up resources to engage across all payer systems for high- and moderate-risk patients and, where possible, at minimum a call for low-risk patients in the early post-discharge period.

Contact: Jeff Hedgepeth
Director, Public Relations & Marketing
Telephone: 252-962-8900
Email: jshedgepeth@nhcs.org