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Stepping Ahead with Care Transitions: New Setting, Outstanding Results

August 9, 2012

Transition Care Team at Christian Health Care Center. Back Row (L-R): Anita Tallman Executive Dir., Pam Colyar FCN, Steve Wallace BSW, LeAna Osterman FCN, Dotty Marston FCN Liaison. Front Row: Lynn Hardaway FCN, Norma Maarhuis FCN.

Lynden Christian Health Care Center (CHCC) re-cently adopted Dr. Eric Coleman's Care Transition Intervention (CTI) for their 24-bed Rehab Unit. The outcomes were amazingly positive. Anita Tallman, Executive Director, said she discovered a "gold mine" in Faith Community Nurses (FCNs) when she learned that over 30 were taught to do the CTI during the Stepping Stones 2008-2011 project. Anita had been searching for a method to monitor the progress of patients following discharge, because their average stay was only 13-15 days. "Our goal was to prevent 30-day hospital readmissions." The efficacy of the Coleman model was very attractive. In high per-forming and low performing markets the 30-day hospital readmission percent was 12% and 35% respectively.* Peace Health St. Joseph Medical Center (PHSJMC) in Bellingham WA. was studied as a "high performing" market in the Stepping Stones era. Anita's appreciation for the skills of FCNs was first hand as they made their usual faith commu-nity visits to people receiving care at CHCC. Thus began her dream for a transition care program run by FCNs.

Four experienced FCN CTI coaches and a nurse-liaison from PHSJMC's Health Ministry Network were contracted to provide this follow-up. It was offered without charge to patients as "your next level of care". The statistical results have been amazing. For the first 6.5 months of 2012 there were 80 patient discharges with 74 accepting the intervention. The program was 100% successful in preventing hospital readmissions within 30 days of discharge. There were zero read-missions. Moreover, of the 6 patients who declined the service, 2 were readmitted to the hospital. The Care Transition Team, including the Lead Social Worker, has also been keeping data about the patient/caregiver's key self-management/patient management skills. In all cases the end scores showed improvement, including more confidence in this role. Patients discharged to assisted living facilities were also followed, resulting in smoother transitions and im-proved coordination.

Success and satisfaction are twins in this program. In the words of CHCC's Executive Director, "The Faith Community Nurses have infused our facility with a sense of mission, compassion and dedication through their work with our resi-dents". A recipient of the Transition Care Program expressed her satisfaction in a note to Executive Director Anita: "I've had the pleasure and security of follow-up care from [FCN]. She met me while I was a patient at the Christian Health Care Center. She followed up by coming to my home and helped clarify some of my medication questions...[FCN] continued to call me at home and offered her support for my rehabilitation. Please accept my appreciation for your efforts in the development of this valuable service." This program has shown that the Care Transition coach role of FCNs in the community can offer outstanding benefits to skilled nursing facilities, hospital re-admission rates, patients, families and caregivers. It is a valuable and needed part of improving the health of Whatcom County.


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