Transition of Care - how are you doing it??

Well first off, I'm still a student so take anything I say with that....

Our local hospital has had several issues with this and a couple of recent failed attempts to improve the situation.

The problem here (which is probably similar to what it is like in other places):

1) Many patients do not have a PCP, so when discharged, they don't have a provider to go to.

2) Many patients when discharged do not have the facilities to get to their PCP.

I suggested a transitionary care team lead by APRNs that could do:

1) Housecalls to patients that were home bound.

2) Care for the patient until the patient was able to get to their PCP if they already had one, and if they did not, either continue caring for them or transition them to another provider.

I also suggested this team work in coordination with the hospital owned home health agency to provide home health and education services for these patients as needed. However, recently it was announced that the hospital was closing down it's home health, so I don't think that suggestion took hold! lol

I have done some market research on the idea, and I know with the numbers we have one provider could be kept busy full time, and you could possibly keep a second busy as well. I think it could be a great opportunity for providers who want to branch out.

I can speak to this from the PCP end.

We are able to run a daily report of our clinic's patients who were discharged from our main hospital the day prior. One nurse runs the report daily. We don't have a protocol for how to do this but I have a routine...review any med changes, ensure timely followup appointment in clinic, coordinate any specialist visit, ascertain any needs (often there are needs!), fix as I am able, refer as not, communicate findings to PCP. Data for this report pulls from a specific EMR template, but it depends on the discharging provider to initiate the template. So despite our robust informatics, this system really depends on the human interface and having someone in the practice to take on the care coordination role.

Zmansc above appears to be referencing the Naylor model, which is really a great model of transitional care, and I feel that an APN can really provide a lot in this type of role -- except for not being able to order DME and home care (and really, who can see these needs better than nurses?? end soapbox)