SLCH Care Transitions Program

WHAT DOES THE CARE TRANSITION PROGRAM DO?

Using the Coleman Model of Care Transitions©, the RN evaluates the patient’s current health status and establishes a plan for meeting the goals of The Four Pillars®.

Pillar No. 1 Medication Self-Management The patient is knowledgeable about their medications and has a system in place to ensure they are taken correctly.

Pillar No. 2 Dynamic Patient-Centered Record The patient understands and manages a Personal Health Record (PHR) to help manage health goals, appointments, questions for providers and medications.

Pillar No. 3 Follow-Up The patient schedules and completes follow-up visits with Primary Care Providers and Specialists.

Pillar No. 4 Red Flags The patient is knowledgeable about signs and symptoms that their condition is worsening, and understands what to do.

CONTACT US

St. Luke’s Cornwall Hospital Care Transition Program General Information ­| (845) 568-2190 Care Transition Program RNs Maureen Monahan, RN mmonahan@slchospital.org Kathleen Liston-Scott, RN kliston-scott@slchospital.org

SLCH RECOGNITION

Healthgrades® 5-Star Recipient Only hospital in Orange County to receive 5 stars for treatment of sepsis in each of the last three years.

Only hospital in the Poughkeepsie-NewburghMiddletown region to receive 5 stars for both natural childbirth and C-Section delivery in 2015.

CARE TRANSITION PROGRAM

American Stroke Association Recognition Received the Gold Plus Achievement Award six straight years for treatment of stroke.

HealthCare’s Most Wired Hospital Named Most Wired three straight years (201416). The honor that recognizes information technology excellence in infrastructure, business and administrative managament, clinical quality and safety, and clinical integration. Earned Most Wired Innovator Award in 2015.

The patient navigates through the pillars via an individualized care plan that is designed by the Care Transition Program RN. The patient’s completion of the Care Transition Program is contingent upon their ability to selfmanage their condition (or demonstrate family management).

Navigating the Health of the Community SLCH#3170 0716

WHAT IS THE CARE TRANSITIONS PROGRAM?

With recent changes in healthcare law, organizations are striving to provide quality, cost-effective care while achieving the best possible outcomes for their patients.

One important focus is navigating or “transitioning” the patient through the healthcare system. This process assists patients in gaining access to the next optimal level of care and ensuring they find the appropriate venue and services to fit their individual needs.

Since it’s inception in 2012, the Care Transition Program at St. Luke’s Cornwall Hospital has helped achieve reductions in readmissions for congestive heart failure (CHF), acute myocardial infarction (heart attacks) and pneumonia. Before the CTP program began, SLCH experienced a 24 percent readmission rate among CHF patients.

Working closely with those patients, the Care Transitions Program has helped reduce that rate to less than 12 percent.

WHO WE ARE

The Care Transitions Program Team consists of: • Care Transition Program Registered Nurses (CTP-RN) • Health Care Coaches (CTP-C) • A Multi-Disciplinary Healthcare Team • A Community Care Coalition • Community Resources

HOW IT WORKS

Patients may be referred to the Care Transitions Program through several sources, including the hospital, their physician’s office, a skilled nursing facility, home health agency or by the patient.

Hospital Staff

WHEN TO CALL US

There is no single, defined time that the Care Transitions Program is appropriate for every patient. Based on each individual’s own circumstances, there are different levels of CTP services to consider.

Acute Level

This experience may be a one-time event in which services are provided, but may not require any follow-up care.

Intermittent Level

This experience may be spaced over periods of time due to a chronic or near-chronic condition. When these periods of illness occur, it may cause a patient to require services on a intermittent basis.

Chronic Level

The chronic experience consists of a more structured and timed approach to interaction with the Care Transitions Program. Examples of chronic illnesses that would require this level of care include congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and end stage renal disease (ESRD).

Palliative/Hospice Level

This experience may be supportive or comforting in nature depending on the patient’s needs and where they are in their continuum of care.

Patients requiring hospital services may be identified by healthcare professionals as candidates for the Care Transitions Program based on their current condition.

Physician’s Office

A primary care provider may identify a patient that would benefit from the services of a Care Transitions Program. Similar to the hospital, this referral is based on the patient’s current condition and their ability to independently manage their health issue.

Skilled Nursing Facility (SNF) or Home Health Agency (HHA) Patients residing in skilled nursing facilities or using home health agency services can be recognized as being able to benefit for Care Transition Program services.

Self-Initiation

Patients may choose to take advantage of the Care Transition Program’s services on their own based on their perceived healthcare needs.

THERE ARE NO COSTS FOR THE SERVICES RENDERED THROUGH THE CARE TRANSITION PROGRAM