Using a DNP-Led Transitional Care Program to Prevent Rehospitalization in Elderly Patients with Heart Failure or Chronic Obstructive Pulmonary Disease

TRANSITIONAL CARE FOR PATIENTS WITH CHRONIC DISEASE BACKGROUND OF PROBLEM: The Affordable Care Act of 2010 has put a spotlight on ensuring safe patient transfers between health care settings to prevent rehospitalization. Hospital readmissions are often influenced by a lack of outpatient transitional care programs to ensure the continuity of care during the transition from the inpatient setting to home. This gap in continuity further exacerbates the issues of patient management of medication regimens, adverse drug events, and follow-up with providers. These exacerbations combined with ineffective symptom management can all result in decompensation and rehospitalization. An extensive review of the literature revealed that transitional care interventions provide innovative and evidence-based methods to prevent the readmission of patients with chronic diseases. Transitional care is defined as a timelimited, patient-oriented service, intended to ensure health care continuity, reduce risk of poor outcomes among at-risk populations, and facilitate safe and effective transfer between levels of care or healthcare settings. OBJECTIVE: To assess the impact of a DNP-led Transitional Care Program (DNP-led TCP) designed to reduce the number of hospital readmissions of elderly patients discharged from a Cape Cod Hospital with a diagnosis of HF or COPD-related illnesses by addressing the complexities of transitions of care. METHODS: Twelve patients with HF or COPD related diagnoses participated in a DNP-led TCP. A prospective one group pre-test, post-test design was used to evaluate the impact of the intervention. The primary outcome measures of 30-day rehospitalization rates for HF and COPD-related illness and 30-day rehospitalization rates for all-causes were collected for the 30 days prior to implementation and 30 days post completion of the TCP. Data was obtained through patient reports and hospital and clinic records. The impact of the TCP on use of emergent or urgent care services for HF or COPD-related symptoms among clinic patients was determined by the percentage of patients in the TCP that documented or reported the use emergent or urgent care services for HF or COPD-related symptoms during the 30 days pre and post TCP. RESULTS: Descriptive analysis was used to examine the change. At the end of the program, the data revealed a decrease from 20 readmissions to zero readmissions in a 30 day period for HF or COPD-related illness. There was a decrease in all-cause readmissions from 21 to zero in a 30 day period. The TCP had a dramatic impact on the use of emergent or urgent care services for HF or COPD-related symptoms among clinic patients. There were 24 visits to the ER among participants in the 30-days prior to the pilot. Eight visits were related to HF, one to an allergic reaction, and 15 were related to COPD. At the day 30 post implementation data collection, ER utilization had rate dropped to zero for HR or COPD related symptoms. This meets the goal of is ≤ 5% of patients receiving the intervention. DNPLED TRANSITIONAL CARE PROGRAM 3 Problem Identification and Evidence of Problem As the Centers for Medicare and Medicaid Services (CMS) transition to the use of Accountable Care Organizations (ACOs) and medical homes, reimbursement is expected to shift from service volume based to quality of care and patient outcomes driven (Feigle, 2011). Under this new system, payers will reward payees for high quality, low-cost care and impose penalties for failure to coordinate care or for increasing costs to Medicare or Medicaid (Feigle, 2011). The expected change spreads the responsibility for effective management of chronic disease over both healthcare organizations and individual providers. In anticipation of such payment plans, many health care organizations and providers are seeking innovative and evidence-based methods to prevent the readmission of patients with the chronic diseases that are the most taxing on the health care system (Hines, Yu, & Randall, 2010). The movement from one health care setting to another marks a care transition and has long been accepted as a danger zone fraught with opportunities for adverse effects and poor outcomes (Anderson & Horvath, 2004; Corbett, Setter, Daratha, Neumiller, & Wood, 2010; Thorpe & Howard, 2006). Corbett et al. (2010) found that 94% of the patients in their sample population experienced a medication discrepancy that occurred during the transition from hospital to home. Coleman (2003) notes that failure to communicate pertinent changes to the treatment plan to the patient and or the next provider is another contributor to poor outcomes. Transitional care is a timelimited, patient-oriented service intended to ensure health care continuity, reduce the risk of poor outcomes among at-risk populations, and facilitate safe and effective transfers between levels of care or among healthcare settings (Parry et al., 2008, Naylor et al., 2011; Stauffer, et al., 2011). DNPLED TRANSITIONAL CARE PROGRAM 4 Naylor et al. (2011) stress that transitional care is meant to complement, not replace, primary care, disease management, discharge planning, or case management. The hallmark of transitional care is the time-limited nature of the program, the focus on fragile patients with chronic illness, and the strong emphasis on teaching patients and caregivers how to prevent avoidable rehospitalization by addressing the underlying causes of poor outcomes (Naylor et al., 2011). Many innovative transitional care interventions have been developed in response to persistent rises in rehospitalization rates despite the additions of “handoff communications” to the 2009 Joint Commission National Safety Goals and discharge planning requirements to Medicare statutes (Parrish, O’Malley, Adams, Adams, & Coleman, 2009). An analysis of hospital readmission rates among patients who reside in the outer regions of Cape Cod highlighted the vulnerability of heart failure (HF) or chronic obstructive pulmonary disease (COPD) patients when they transition between healthcare settings. Many of the problems identified stem from poor continuity of care and are most detrimental when patients are discharged from inpatient settings to home. These service gaps supported the need for a DNP-led transitional care intervention that is patient-centered and arms patients with the knowledge, support, and tools necessary to shift from the dependence of the inpatient setting to taking an active role in managing their disease in the outpatient setting. The opportunities for improvement fell within the concepts of post-discharge medication management, early provider follow-up, up-todate accessible medical records, and self-care/symptom management. To address the complexities of transition, a Doctor of Nursing Practice (DNP) candidate developed and pilot tested a community-based nurse DNP -led Transitional DNPLED TRANSITIONAL CARE PROGRAM 5 Care Program (DNP-led TCP). Initially designed to prevent repeated hospitalizations of patients with heart failure, the DNP-led TCP was expanded to include patients with other chronic diseases. This paper will provide a discussion of this Doctor of Nursing Practice (DNP) candidate’s experience in designing, implementing and evaluating a program that successfully ensured that patients and families possess the tools, knowledge, and support for self-management of their disease in partnership with their health care provider.