News Releases

Dr. Naylor Presents Transitional Care Model Addressing High Rates of Readmissions

On Wednesday, Dec. 7, more than 150 individuals representing various healthcare settings attended A Community-Based Approach to Improving Care Transitions & Reducing Rehospitalizations, held at Cuyahoga Community College - Corporate College East. This half-day learning event, which was scheduled based on the success of the Transitions of Care conference featuring Eric A. Coleman, MD, MPH, held in early November, featured keynote speaker Mary Naylor, PhD, FAAN, RN, as well as four concurrent breakout sessions. Dr. Naylor is the Marian S. Ware Professor in Gerontology, Director of NewCourtland Center for Transitions & Health, University of Pennsylvania School of Nursing.

Dr. Naylor presented her Transitional Care Model (TCM) that addresses high rates of readmissions. The TCM provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. The heart of the model is the Transitional Care Nurse (TCN), who follows patients from the hospital into their homes. While TCM is nurse led, it is a multidisciplinary model that includes physicians, nurses, social workers, discharge planners, pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients' and caregivers' ability to manage their care.

Her presentation, Transitional Care Model: Evidence-Based Transitional Care for Chronically Ill Older Adults, identified ten essential elements of the TCM, including:

• The TCN as the primary coordinator of care to assure consistency of provider across the entire episode of care;
• In-hospital assessment, preparation, and development of an evidenced-based plan of care;
• Regular home visits by the TCN with available, ongoing telephone support (seven days per week) through an average of two months post-discharge;
• Continuity of medical care between hospital and primary care physicians facilitated by the TCN accompanying patients to first follow-up visits;
• Comprehensive, holistic focus on each patient's needs including the reason for the primary hospitalization as well as other complicating or coexisting events;
• Active engagement of patients and their family and informal caregivers including education and support;
• Emphasis on early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to readmissions;
• Multidisciplinary approach that includes the patient, family, informal and formal caregivers as part of a team;
• Physician-nurse collaboration; and
• Communication to, between, and among the patient, family and informal caregivers, and health care providers and professionals.

Following Dr. Naylor’s presentation, hour-long concurrent breakout sessions were held. Attendees had their choice of four unique learning topics, including:

• Role of Home Care in Reducing Readmissions
  In this breakout session, Steven Landers, MD, Director, Home Health Care Cleveland Clinic, focused on important demographic, epidemiologic, and policy trends portending  an increasing emphasis on home and community-based healthcare. He also explored the concepts and models of home-based healthcare that can reduce hospital readmissions.
• Fostering Patient Engagement:  Better Health Through Engaged Teaching
  In this session, Janet Kloos, RN, PhD, CCRN, Clinical Nurse Specialist, University Hospitals Case Medical Center; Joyce Thomas, RN, BSN, Clinical Nurse Specialist, University Hospitals of Cleveland; and Janice Lombardo, Member of Patient & Family Council, focused on building a culture that recognizes that having the patient and family as partners in healthcare can contribute to improvement goals. They also explored the role of patients and three methods to engage them.
• Effective Teaching & Learning: Implications for Patient Care
  This breakout presented by, Barbara Halliday, MSN, RN, ACNS-BC, Clinical Nurse Specialist in Cardiology, MetroHealth Medical Center and Sharon Mack, MSN, ACNP-BC, CHFN, IA, Nurse Practitioner, Heart Failure Section, MetroHealth Medical Center, focused on a framework to guide the patient education component of the discharge planning process. They also explored literacy issues and related strategies to facilitate the learning process.
• Performance Improvement: A Character Building Experience
  In this breakout session, Jennifer Andrey, MSN, RN, CNP, Director, Cardiac Program, Cleveland Clinic Western Region, focused on three elements of meaningful quality metrics for re-hospitalization initiatives and the potential financial impact of process improvement for hospitals.

Prior to the December 7 event, The Community-based Care Transitions Steering Committee, which was formed as a result of more than 90 individuals who expressed interest following the first Transitions event held in November, held a brief introductory meeting.

This new committee will meet again in early 2012 to further develop a framework and organizational structure for establishing multi-stakeholder work groups to collaboratively find solutions to improve care transitions and reduce avoidable hospital readmissions across the region.

This event was sponsored by The Center for Health Affairs and Better Health Greater Cleveland, and funded by the Robert Wood Johnson Foundation - Aligning Forces for Quality.

For additional information about the December event or the newly formed Steering Committee, please contact Linda Neiding at 216.255.3666 or linda.neiding@chanet.org, or Lisa Anderson at 216.255.3660 or lisa.anderson@chanet.org.