Two programs by Via Christi Health dedicated to reducing readmissions of patients after their discharge from the hospital have been recognized by the Kansas Healthcare Collaborative (KHC).
The programs, Community Cares and the Transitions Clinic, were the result of a concentrated effort to reduce readmissions begun in December 2013, when six teams were formed at Via Christi Hospitals in Wichita, Kansas. What came to be known as “Team Six,” co-led by Jennifer Jackson, MD, and Jennifer Rodgers, APRN, began focusing on Transitions of Care. An interdisciplinary team including representatives from respiratory therapy, rehabilitation services, pharmacy, home health/durable medical equipment, social work, Clinical Excellence and palliative care came together to develop a plan that involved the development of Community Cares and the Transitions Clinic.
KHC honored the programs with a Leadership in Quality Award in the category of “Achievement in Care Transitions that Address Readmissions.”
“We’re so proud of the associates at Via Christi who received this recognition for their excellent work to reduce readmissions,” said Debbie Rapp, RN, MSN, ACNS-BC, Senior Director, Clinical Excellence, Ascension Health. “The interdisciplinary team’s collaborative effort to work throughout the continuum of care is a great example of what is being achieved across Ascension to provide our patients with more pillow nights at home.”
Community Cares
Community Cares was developed in April 2014 with funding assistance from Ascension Health. This program focuses on high-risk patients with chronic obstructive pulmonary disease who have frequent readmissions and are home bound or nearly home bound. Nurse practitioners provide live/virtual home visits as well as provide 24/7 on-call support for patients and their families.
This new model of care takes the “clinic” to the patient and bridges care across the continuum for these individuals, who have a very high incidence of readmissions. The visits are person-centered, focusing on the physical, mental, spiritual and psychosocial needs of the patient and their families.
Patients enrolled in the program have had an 80 percent reduction in readmissions and in emergency department visits. Patients in Community Cares receive the right care, in the right setting, at the right time. Community Cares currently touches patients throughout Wichita and as far south as Wellington, Kansas, working with multiple providers, safety net clinics, pharmacies, home health and hospice, durable medical equipment, mobile lab and radiology services.
Transitions Clinic
The Transitions Clinic opened in June 2014. The concept focuses on bridging patients from an acute care stay back into the community. Patients who do not have a primary care provider, cannot get in to be seen by their provider within seven days, or are awaiting transition to a safety net clinic are offered appointments at the Transitions Clinic, where a nurse practitioner, a registered nurse and a social worker see them. This team works with the patient and families to ensure a safe transition to a primary care provider.
Nearly 80 percent of these patients are non-funded, with multiple co-morbidities, and are high utilizers of the emergency department and inpatient system at Via Christi. An extensive amount of time is spent with medication management, post-hospital disease management of the patients’ multiple acute and chronic health problems, psychosocial and spiritual support, and coordination of multiple services in order to bridge the patient safely into the community.
The initial 50 patients seen in the Transitions Clinic had a combined 375 emergency department (ED) and hospital visits in the 12 months prior to the launch of the program. After being referred to the Transitions Clinic, they had a total of two ED visits and one inpatient admission.
