Case Studies
Longitudinal Discharge
One successful initiative can lead to another. A “nurse transitionist” program at Western Maryland Regional Medical Center, a 275-bed hospital in Cumberland, MD, has contributed to a reduction in readmissions. This program and several other initiatives have helped WMRMC decrease readmissions from more than 20% to an average of 6% to 8%. “It was a remarkable turnaround, but it didn't come easily,” says Barry P. Ronan, president and CEO. The nurse transitionist program started with collaboration between the medical center and its own nursing home. The nurse transitionist ensures all paperwork and instructions are set before a patient's discharge. When transferred, the patient is seen by the NT, who connects with the next caregivers, reconciles medications and, in general, eases the transition. At days 5, 12 and 15 after discharge, the NT visits the patient. All staff at the nursing home, including the NT, can connect to the hospital, using an iPad on a secure network, for needed assessments. Ronan calls this discharge “longitudinal” as it “goes beyond traditional discharge.” One key is regularly assessing patients: A team of caregivers, including care managers, visits every patient who has stayed three days or longer in the hospital. The first three months of the NT program resulted in zero readmissions. Plans are under way to expand this program to other nursing homes in the region.
One successful initiative can lead to another. A “nurse transitionist” program at Western Maryland Regional Medical Center, a 275-bed hospital in Cumberland, MD, has contributed to a reduction in readmissions. This program and several other initiatives have helped WMRMC decrease readmissions from more than 20% to an average of 6% to 8%. “It was a remarkable turnaround, but it didn't come easily,” says Barry P. Ronan, president and CEO. The nurse transitionist program started with collaboration between the medical center and its own nursing home. The nurse transitionist ensures all paperwork and instructions are set before a patient's discharge. When transferred, the patient is seen by the NT, who connects with the next caregivers, reconciles medications and, in general, eases the transition. At days 5, 12 and 15 after discharge, the NT visits the patient. All staff at the nursing home, including the NT, can connect to the hospital, using an iPad on a secure network, for needed assessments. Ronan calls this discharge “longitudinal” as it “goes beyond traditional discharge.” One key is regularly assessing patients: A team of caregivers, including care managers, visits every patient who has stayed three days or longer in the hospital. The first three months of the NT program resulted in zero readmissions. Plans are under way to expand this program to other nursing homes in the region.
For more information, contact Carol Everhart, director of care coordination, at ceverhart@wmhs.com.