Transitional Care Programs

By Kindred Healthcare

Illinois Family Home Health Services (IFHHS), an affiliate of Kindred at Home, originally developed a Care Transition Program in anticipation of and in response to the October 1, 2012, hospital readmission reimbursement cuts. With the changing landscape of healthcare, IFHHS sought to improve on its better-than-average hospital readmission rates and develop these programs with the needs of hospital discharges in mind.

Currently we have specific Transitional Care Programs for COPD, diabetes, wound care, CHF, and orthopedic patients. The first step in developing the Transitional Care Programs was to identify what things we were already doing that were effective in keeping hospital readmissions down. Our telemonitoring program had been a good way to supplement the clinician visits for its patients. Patients would then get follow-up calls to check vitals and assess condition on non-visit days. These calls could then be tracked within the system and, if needed, the case manager could be contacted in the event of an issue, which was crucial in avoiding certain rehospitalizations. All patients in the Transitional Care Programs are included in telemonitoring as well.

All patients are also given diagnosis-specific self-care kits. These kits include tools to assist the patient and caregivers in disease management and control. As many healthcare professionals can attest to, patient compliance is often the biggest challenge in improving outcomes. By giving patients the tools and education to self manage, along with the accountability of the visits and telemonitoring calls, they are empowered to manage their own conditions.

Another aspect of fostering positive patient outcomes is understanding healthcare providers’ need to work together to leverage their strengths for the benefit of the patient. IFHHS developed strategic relationships with Abbot Labs in including their nutrition intervention program for care transitions. This program was developed by Abbot using specific diagnosis-based dietary supplements with the goal of reducing hospital readmissions and better patient recovery post-hospital discharge.

We also have a strategic relationship with a local pharmacy program where patients who are enrolled can have a face-to-face pharmacy tech consult to go over their medication and any changes. Evidence suggests that a large number of hospital readmissions are due to medication mismanagement. Care Transition patients are offered this program as a way to mitigate that risk.

Transitional Care Programs All nurses take competencies in the various programs allowing them to treat their patients with a higher level of care. IFHHS is now in the process of expanding its Transitional Care Programs to include lymphedema wraps. Under the new Kindred affiliation, IFHHS is seeking to be known in the Chicago market as specialists in transitional care in the home.

COPD Patient Success – Kenneth

Kenneth had been hospitalized multiple times over a three-month timeframe with exacerbations of COPD. Upon his most recent discharge, he was admitted to home health with the hospital discharge planner specifically instructing that our goal was to prevent rehospitalization. Both the patient and caregiver were educated verbally and with the COPD patient care kit, along with supplemental telemonitoring. He has not been readmitted and he continues to be seen for continued assessment, teaching and support. It has been over seven months since his hospital discharge.

Diabetes Patient Success – Charles

Charles has a history of diabetes and morbid obesity. He had a wound on his lower extremity that he had been dealing with for over a year. It progressed to a severe cellulitis and he developed numerous open, draining wounds. Since being admitted for home health, nursing has seen him for education and daily dressing changes. The case manager was supported by the agency wound care specialist, and follow up on his condition was done by case manager visits. Within a month of his admission and with the help of both the Wound Care and Diabetes programs, the wounds have all closed and Charles now has only some patches of dry skin which are resolving quickly and his diabetes has remained under control.