Nearly two decades ago, Alice Jackson* began struggling with a range of symptoms, including coughing, wheezing and shortness of breath, and was diagnosed with chronic obstructive pulmonary disease (COPD). Almost always caused by smoking, COPD also can result from breathing in dust, chemical fumes or other contaminants over an extended period of time.
Originally from New Jersey, Jackson moved to Caroline County in 2008 to be closer to her nephew’s family. Since 2014, she has experienced increasing difficulty in managing her COPD symptoms and made repeated trips to the Emergency Department at UM Shore Medical Center at Easton, followed by inpatient stays in the hospital and also in skilled nursing facilities for rehabilitation.
“It seemed like every other month or so, I’d have another flare-up and wind up back in the hospital and then in a nursing home,” Jackson recalls.
In October 2017, Jackson experienced another exacerbation and was admitted to UM Shore Medical Center at Easton for a five-day stay. She was discharged to a rehab facility, but her stay was cut short for insurance reasons. “I had already used all my inpatient rehab days that Medicare would pay for, so I had to go home,” says Jackson, who lives alone.
Fortunately for Jackson, UM Shore Regional Health had implemented the new Transitional Nurse Navigator (TNN) Program, which brings a new approach to the discharge process for patients, like Jackson, whose chronic illnesses increase their risk of being readmitted to the hospital. During and after her hospital stay, Jackson worked closely with a social worker and Lori Geisler, MSN, RN, one of four transitional nurse navigators involved in patient care at UM Shore Medical Centers at Chestertown, Dorchester and Easton.
“I felt like I had more support this time. They were fantastic,” says Jackson. “They really went to bat for me with my insurance company to make sure I got my oxygen, my hospital bed and my supplies and equipment for Coumadin and glucose testing. They also helped arrange to have in-home rehabilitation visits from a physical therapist and an occupational therapist.”
Now under the care of primary care provider Kim Herman, MD, in Denton, and pulmonologist Funlola Famuyiwa, MD, in Easton, Jackson also appreciates having an in-home aide several hours a week and support from her local community, including lunches prepared and delivered by local church volunteers. “I’m glad to be staying out of the hospital and doing better at home,” she says.
*Name and certain details have been altered in the interest of patient privacy.
ANTICIPATING PROBLEMS, OFFERING SOLUTIONS
UM SRH launched the Transitional Care Program in 2017 to help reduce the number of people with avoidable or unplanned readmissions to the hospital within 30 days of discharge. People with COPD, as well as people with congestive heart failure and pneumonia, are at high risk of readmission, so the program targeted those groups first.
Here’s how the program works: When high-risk patients arrive at the emergency department or are admitted to UM Shore Medical Centers at Chester town, Dorchester or Easton, a transitional nurse navigator tracks their care to help make sure they will have everything they need when they are discharged.
Angela Pritzlaff, RN, transitional nurse navigator for UM SMC at Chestertown, says she targets a range of potential issues when she works with patients—problems with medications, psychological issues, their main health condition and other health concerns, physical limitations, health literacy, family support, prior hospitalizations and palliative care.
The newest member of the Transitional Nurse Navigator team is Marybeth Daniels, MS, RN, PCCN. A resident of Cambridge, Daniels is happy to be assisting patients during and after discharge from UM Shore Medical Center at Dorchester. “I think it’s always a pleasure to help the people in your own community,” says Daniels.
Depending on what problems are identified, the nurse navigator helps patients by:
- Scheduling follow-up appointments with primary care doctors and specialists, and assisting with transportation arrangements if needed
- Making sure the patients and family members understand their health condition and know what to do if problems arise
- Helping them obtain, understand and manage their medication
- Communicating with skilled nursing facility staff if patients are discharged there
““We talk to the patient to try to find out what problems brought them back to the hospital or tend to bring them back. We try to make sure they have everything in place to prevent readmission. If they have problems getting medications or can’t keep their doctors’ appointments, we help come up with a solution,” Geisler explains.
Transitional nurse navigators follow up with phone calls to their patients and in some cases, home visits. “We’ve caught things in the follow-up phone calls that helped patients avoid coming back to the emergency department and possibly being readmitted,” says Melissa Eigenbrode, MSN, RN, transitional nurse navigator for UM SMC at Easton.
If patients are discharged to a skilled nursing or other residential care facility, nurse navigators connect with staff there to make sure they will have their medications, any needed equipment or supplies, meals that meet their dietary needs, and timely transportation to and from doctors’ appointments.
According to Nancy Bedell, MBA, RN, regional director of care coordination, the Transitional Nurse Navigator Program is a key population health initiative that supports Shore Regional Health’s mission of Creating Healthier Communities Together. “The goal here is to help people be well and to be able to take care of themselves and their families,” Bedell says.
Editor’s Note: This story is excerpted from the Spring 2018 issue of Maryland’s Health Matters, scheduled for publication in April 2018. Keep reading Compass for information about population health strategies in progress at UM SRH.