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Nurse Practitioner–Led Transitional Care Program Does Not Reduce Readmissions During Period Between Discharge and Followup Appointment

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The Visiting Nurse Service of New York created a transitional care program led by a nurse practitioner to bridge the gap in care for recently discharged patients who require home health care and are awaiting a followup appointment with a primary care physician. The nurse practitioner conducts an initial assessment to identify eligible at-risk patients; develops the patient's transition plan before discharge; communicates the transition plan to relevant providers; and supports the home health nurse and patient during the transition period. Although the program improved transitional care and reduced waiting times for followup appointments, it did not meet its primary objective of reducing unplanned readmissions.
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Developing Organizations

Visiting Nurse Service of New York
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Date First Implemented


Problem Addressed

Recently discharged patients often lack adequate knowledge of how to manage their conditions and access health care resources, making them particularly vulnerable to negative outcomes, including readmission and/or death, during the time period (typically a few days to more than a month) when they are waiting for a followup appointment.
  • Complex needs, but little knowledge of how to manage them: Many patients discharged to home health and/or community-based care have multiple comorbid conditions, but most have not been adequately educated on how to manage them. As a result, some patients do not adhere to prescribed care regimens. For example, patients often fail to fill prescriptions because they do not understand the importance of taking their medications and/or think they are not worth the expense.1
  • Little information transfer to community-based providers: Home health agencies and other community-based providers often do not receive adequate information about patients who have recently been discharged from the hospital, including what medications they should be taking (which is due in part to poor medication reconciliation) and what type of care they require to address their multiple health problems.1
  • Leading to frequent readmissions, deaths: More than 57,000 avoidable deaths occur each year because of "quality gaps," many of which are the result of poor communication at handoffs, including when patients transition from the inpatient setting to home health or community-based care.1 The Visiting Nurse Service of New York found that the failure to address the needs of recently discharged patients led to high readmission rates among patients with multiple chronic illnesses. This problem was due in part to the long time lag between discharge and the patient's followup appointment and to the many difficulties that patients faced in reaching a physician during this period.

What They Did

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Description of the Innovative Activity

Visiting Nurse Service of New York created a transitional care program led by a nurse practitioner to bridge the gap in care for recently discharged patients who require home health care and are waiting for a followup appointment with a primary care physician (PCP). The goal is to address proactively psychosocial and other issues that frequently prevent patients from managing their illness at home, thus leading to high readmission rates. Under the program, the nurse practitioner conducts an initial assessment to identify eligible at-risk patients, develops the patient's transition plan before discharge, communicates the plan to relevant providers, and supports the home health nurse and patient during the transition period. Key elements of the program include the following:
  • Identifying eligible patients: Using databases from both the Visiting Nurse Service of New York and Mt. Sinai Hospital, the nurse practitioner identifies hospitalized patients who are active clients of the nurse service. The hospital also refers patients in need of home health services to the nurse practitioner, who conducts a needs assessment on behalf of the visiting nurse service and completes the discharge planning process. On average, the nurse practitioner receives approximately 20 to 25 referrals each week from the hospital (most are new clients) and handles a caseload of approximately 100 clients at a time.
  • Assessing patients: The nurse practitioner visits all eligible patients in the hospital to conduct a global assessment that covers three areas, as described below:
    • General assessment: The nurse practitioner spends roughly 90 minutes with each patient, asking him or her to discuss the circumstances surrounding the admission, personal goals after returning home, disease management skills, medication compliance before admission, and disposition preferences related to managing the disease. By asking patients about their specific goals, the nurse practitioner is able to elicit additional psychosocial information not typically captured in the medical record, including any barriers the patient faces in managing medical care after discharge.
    • Readmission risk assessment: The nurse practitioner assesses the risk of readmission and determines the level of postdischarge support the patient requires to minimize the chance of readmission. Each risk level has a corresponding standardized care plan designed to support the patient in the home.
    • Chart review and family interview: The nurse practitioner reviews the patient's hospital chart (and Visiting Nurse Service of New York chart if applicable) and speaks with family members to develop a clearer picture of the patient's postdischarge needs.
  • Developing and communicating detailed transition plan: Using the information gathered during the assessment, the nurse practitioner develops a patient-centered transition plan to supplement the discharge plan created by the floor nurse. The nurse practitioner reviews this plan with the attending physician, gets his or her approval, and then communicates the plan to the PCP at the internal medicine clinic and the home health nurse.
  • Patient education: On discharge, patients receive an easy-to-read chart that includes the names of their medications, the purpose and appropriate dosing for each, and administration times. Patients also receive an "action plan" with a list of potential symptoms and medical problems they may encounter, with accompanying explanations of what to do if they experience any of them (e.g., when to call the home health nurse or 911).
  • Postdischarge support: After discharge, the nurse practitioner is available to support the home health nurse and patient to ensure continuity of care by performing the following services:
    • Medication reconciliation: The inpatient physician prescribes the patient’s discharge medications based on the list provided by the patient and the doctor’s preferences. If the home health nurse discovers any problems with the prescribed regimen, he or she contacts the attending physician or the patient’s PCP. If neither is available, the nurse contacts the nurse practitioner, who has prescribing privileges and can reconcile the patient's medications.
    • Transitional care monitoring: After discharge, the home health nurse monitors the patient, including his or her ability to follow the discharge plan. The nurse communicates any problems to the nurse practitioner, who takes appropriate action to rectify the situation. The nurse practitioner is available as a resource to the field nurse during the few weeks between discharge and the followup PCP appointment, a period of time when the patient is at the greatest risk for a problem.
    • Home visits for at-risk patients: The nurse practitioner makes home visits to patients identified as being at high risk for readmission. During the visit, the nurse practitioner provides additional education and training to patients about their condition, including self-management strategies. The nurse practitioner may also review the patient’s prescriptions and medication compliance, making changes to the regimen as needed.

Did It Work?

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Although the program improved transitional care and reduced waiting times for followup appointments, it did not meet its primary objective of reducing unplanned readmissions.
  • Improved transitional care: The majority of participants are receiving more comprehensive care during the transitional period between discharge and followup appointment. For example, 80 percent of eligible patients are assessed by the nurse practitioner before discharge, 81 percent receive increased nursing support in the home during the transitional period, and 77 percent of high-risk patients are assigned a social worker (up from only 23 percent before program implementation).
  • Quicker followup appointments: Before implementation of the program, it took roughly 30 days for discharged patients to see the PCP at the clinic. After implementation, the average wait fell to 18 days.
  • No change in unplanned readmissions: The rate of unplanned hospitalizations for project participants was approximately 34 percent, the same as for patients who did not receive the intervention.

What They Learned

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  • Develop/refine system to identify at-risk patients: Develop a methodology to uncover risk factors for rehospitalization that could be affected by nurse practitioner interventions. Possible risk factors to consider include level of self-management skill, level of social support, and gaps in the patient's medical home. In addition, when thinking about the most effective risk assessment tool, consider how the patients identified will be affected by the nurse practitioner's role. In this project, developers found that the risk assessment tool identified the patients at highest risk for rehospitalization, but the added interventions did not reduce unplanned hospitalizations. As a result, developers have decided to consider alternative risk assessment tools.
  • Forge partnerships: The hospital and home health agency need to work together to serve at-risk patients. For example, hospitals must allow nurse practitioners to obtain privileges to work within their facilities. Since initial implementation, the Visiting Nurse Service of New York has made significant inroads in this area by having the Mount Sinai Hospital agree to credential the Visiting Nurse Service nurse practitioner as if she/he were a Mount Sinai nurse practitioner. The Visiting Nurse Service of New York also hopes to enhance its relationship with the hospital by changing the practice setting of the nurse practitioner to the hospital's emergency department (ED); project developers hope that this change will benefit both organizations, because all clinicians involved in discharge planning decisions will be located in the same place.
  • Consider psychosocial factors: Unplanned readmissions often result from poor self-management skills and complex psychosocial factors (rather than poor medical management). Carefully consider and address the nonmedical psychosocial reasons for unplanned readmissions, which can be present even in low-risk populations. Although the first iteration of this project focused on psychosocial factors and self-management skills, the workflows, nurse practitioner role, and risk tool did not highlight their impact on the initial hospital stay and rate of rehospitalization. Project developers are planning on formalizing ways in which the nurse practitioner can leverage his/her scope of practice to improve patient self-management. These strategies could include both more structured time with patients and families to focus on self-management skills, and bringing in field nurses to mentor and conduct their own self-management work with patients.
  • Evaluate nurse practitioner's role: This project structured the nurse practitioner's role as a clinical support to the home care nurse and PCP, despite the nurse practitioner's ability to prescribe and reconcile medications, change orders, and provide patient and nurse education. However, the nurse practitioner can play a more central role for the patient and health care system, and this role might help to reduce the rate of unplanned hospitalizations. As this project is refined, the role and settings of the nurse practitioner will change. Going forward, the nurse practitioner will work approximately half time in the ED and half time in patients' homes. In addition, rather than serving in a consulting role to the field nurses and the PCPs, the nurse practitioner will be placed into the daily activities related to patients' discharge from the ED (when home care services are ordered). In effect, the nurse practitioner will serve as an "interim PCP," meaning he/she will be the primary clinician responsible for the medical management of the patients from the point of ED discharge to the time they return to their PCP or other main physician for their first post-ED medical appointment. This change means that the relationship between the nurse practitioner and the field nurse shifts to one in which the registered nurse is receiving orders, both medical and nursing, from the nurse practitioner. In addition, the nurse practitioner will be communicating on a more level playing field with the PCP.
  • Embed tools into existing technology: Integrating paper-based evaluation tools (e.g., for risk stratification) into existing electronic technology (as a required field) encourages practitioners to use the tools and enhances the ability to produce reports that cover a broad range of patient outcomes. This project has recently made one change in its electronic database—the original risk assessment tool that predicted rehospitalization was embedded in January 2008 as a required form for all field nurses to complete on patient admission to home care. Previously, only the project nurse practitioner used this form as a paper tool. Next steps are for the nurse practitioner to use paper tools in performance improvement change cycles, with a view toward embedding the most effective ones into the electronic database.

More Information

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Contact the Innovator

Noreen Coyne, RN, MSN, OCN
Clinical Product Development Specialist
Visiting Nurse Service of New York
5 Penn Plaza, 12th floor
New York, NY 10001
(212) 609-1767

MaryJo Vetter, MSN
Visiting Nurse Service of New York
5 Penn Plaza, 12th Floor
New York, NY 10001
(212) 609-6358

Innovator Disclosures

Ms. Coyne and Ms. Vetter have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles



1 The Joint Commission. Patient handoffs: making the hospital to home care transition. The Joint Commission Perspectives on Patient Safety. 2008;8(1):1-4.
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Original publication: July 20, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 22, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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