COPC Transition of Care
Goal is to decrease readmission rates
COPC Hospitalist Services • Rounding on avg. of 230 (range170-290) patients per day
• Avg. 40-50 patient discharges per day • 50% of these patients have a COPC PCP
Transition of Care Nurses (TCN) • 5 fulltime Registered Nurses • Access to medical record and history for 50% of hospitalized patients • 350,000 patients in EHR in last 2 years
TCN Workflow • Every admission seen by TCN • Post discharge appointment set up for all COPC PCP patients • Post discharge appointment set up for all nonCOPC patients with dx: CHF COPD
Pneumonia MI Diabetes complication
• HER notification to PCP
Post Discharge TCN workflow • Call at 72 hours to every patient • Protocol: How are you feeling? Any Concerns? Medication Reconciliation Review plans for follow-up appt EHR notification to PCP prn
Results/DATA • Medicare 30 day readmit National avg. ~18% • COPC 18 month avg. • 24/7 hospitalist + TCN
15% 6.2%
• 1994 Dr. Mary Naylor showed transitional care management could decrease Medicare readmissions by as much as 60% (1) (1) Ann Int Med. 1994 vol 120
New Initiative Post Discharge to SNF • Another chance to “drop the ball” • Where is the patient going if not to home? • 40% of Medicare patients are discharged to a skilled nursing facility or rehab facility • 30 day readmit rate for these patients is >20%
COPC SNF Initiative • COPC have begun placing our hospitalists in SNF units • SNF patients have increasing acuity and management by a hospitalist may be indicated • Hospitalists with CNP’s will manage COPC patients in SNF units • Patient Flow: PCP to Hospitalist to SNFist back to PCP • DATA will come from SNF readmission numbers