1. Richardson, Barbara M. MSN, RN-BC, CCRN


In this month's Magnet(R) Perspectives column, Barbara Richardson, MSN, RN-BC, CCRN, clinical nurse specialist at the Southwestern Vermont Medical Center, examines the ways in which a robust transitional care program improves community health, reduces readmissions and emergency department visits, and provides valuable social support for even the most complex patients. Richardson shares critical factors that impacted the program's success, including a Magnet(R) environment of innovation, a visionary hospital leadership team, strong community alliances, and collaborative solutions to previously intractable problems. Her efforts to build and implement a successful transitional care program earned Richardson the 2016 National Magnet(R) Nurse of the Year Award for Structural Empowerment.


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Keeping people healthy and out of the hospital are key concerns for today's healthcare organizations. As care moves from inpatient to outpatient settings and into the community, it is essential that providers refocus their attention to meet the increasing need for resources outside hospital walls.

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At the Southwestern Vermont Medical Center (SVMC), a robust transitional care program helps achieve this goal. Transitional care is the coordination of healthcare as patients move from 1 setting to another. Transitions are risky for all patients, but those with chronic conditions and factors such as functional deficits or social barriers are especially vulnerable. It is a time when things can fall through the cracks and send patients back to the hospital. Transitional care helps people navigate through the pitfalls that arise, such as confusion over discharge instructions, medication mismanagement, or failing to recognize early warning signs of a health issue.


The seeds of our program sprang from a confluence of factors: the census at our small, rural hospital was declining, and readmission rates were climbing. Patients, often older adults and with low income, were discharged home while still frail. Although clearly in need, they could not access community resources because they did not meet the criteria. Predictably, many of these patients ended up back in the hospital.


My fellow clinical nurse specialists and I wondered how we could use our skills and training to help these patients outside the hospital setting and reduce readmissions. We put our heads together and found Mary Naylor's Transitional Care Model.1 After we modified it for our community with permission, hospital leadership gave us the green light to move forward.


Transparency and communication helped drive our early success. From the beginning, we sought the approval of our community peers. We assured them we wanted to augment, not duplicate, their resources. As long-time employees, we enjoyed strong ties with the physician community and home health agencies, which helped with buy-in and program development. Physicians, home health nurses, nursing home rehabilitation staff, and inpatient case managers all contributed critical input.


We launched our program in 2014. Each of our transitional care nurses partners with a local primary care office. The nurses identify patients who could use extra help transitioning from hospital to home. They identify appropriate patients in the hospital, follow up soon after discharge, and make home visits. They help patients create a beneficial routine, organize medications, and understand their symptoms. They also work to create a communication bridge between the hospital and primary care physician, so each has better information about the patient's history.


Patients are followed for up to 3 months. Our chief focus is to help them navigate that crucial early period when problems may arise. We try to be in the home within 24 to 48 hours to catch issues such as medication errors early on and teach patients how to take good care of themselves.


Our program shows remarkable results. Readmissions have dropped 69%, and emergency department (ED) visits are down by 26%. Anecdotal tracking of medication errors indicates that we have made an impact in this area as well, although we do not yet keep official data. Because of these results, the state of Vermont awarded our team a $200 000 innovation grant, which we have used to address critical gaps in community resources.


When our program began, we had no idea of the breadth and depth of health illiteracy and social and financial poverty in our region. Grant money enabled us to hire a part-time social worker to tackle many of these issues. The funds also support inpatient medication education and in-home pharmacist visits, which benefit patients with complex medication regimens. We have implemented an evidence-based program that gives nursing home staff a pathway to monitor and report changes in patients. By catching and managing problems early, we have reduced readmissions from nursing homes to less than 5%.


Despite this success, we still struggled with patients showing up in the ED repeatedly. No matter how many resources we put in place, the problem persisted. Inspiration came from a presentation at the 2013 ANCC National Magnet(R) Conference entitled "Developing a Community Care Team to Reduce ED Readmissions; Structure, Process, Outcomes." Staff from Middlesex Hospital in Connecticut shared their successful efforts to address high ED readmission rates. The patient population they described resonated with us, and we were able to reproduce their work. Following their template, we used grant money to assemble a community support network that spans multiple agencies and areas. We also hired a patient advocate, based in the ED, who identifies repeat patients and develops a plan to meet their needs. Patients who were coming in as frequently as 2 to 3 times a day are now staying out of the ED for months. Our team ensures they get the resources they need. For only about every gap we have identified, we have found a large or small way to fix it.


In the end, it comes down to culture. The SVMC is a unique environment. It has always been a little hospital that thinks it can do big things. Nurses are encouraged to bring ideas forward. These hallmarks of a Magnet(R) culture allowed us to create something that did not exist. We had to work for it, but our leaders never shut the door on us.


Our program not only improves quality of life in our community but also lets us see the long-term benefit to patients. Nurses in a hospital setting rarely get this opportunity. My fellow transitional care nurses and I agree: it is the most rewarding work we have ever performed.




1. Hirschman K, Shaid E, McCauley K, Pauly M, Naylor M. Continuity of care: the transitional care model. OJIN. 2015;20(3):Manuscript 1. Accessed April 23, 2017. [Context Link]