TROY – Transition care is a phrase that followers of health care news can expect to hear more and more about. It is the process by which patients are moved (transitioned) through the health care system from one level of care to another as their individual needs require.
Transition care is especially critical for patients with chronic diseases such as diabetes, congestive heart failure and COPD. Because of their age or other barriers, these patients often find it difficult to self-manage their condition, resulting in high hospital readmission rates and repeat emergency department visits.
FirstHealth of the Carolinas, which has had a transition care component to its home health program for several years, took the concept to a different level of service with the opening of a Transition Care Clinic (TCC) on the campus of FirstHealth Moore Regional Hospital in Pinehurst last fall. A recent grant from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (DHHS) will now allow FirstHealth to open similar clinics in Montgomery, Richmond and Hoke counties.
The total value of the three-year grant, made through HRSA’s Small Health Care Provider Quality Improvement Grant Program, is $450,000.
The first of the three clinics is scheduled to open in March in the Medical Arts Building adjacent Montgomery Memorial Hospital. Clinics will follow in Richmond and Hoke counties.
According to Roxanne Elliott, policy director of FirstHealth Community Health Services, the project has two goals: to help patients learn to self-manage their disease and to create a chronic disease care model that can be implemented within FirstHealth primary care practices.
“We want to see what will work in rural, small health care situations,” Elliott says. “We will be looking for doctor and patient feedback in terms of clinical outcomes and quality of life.”
The TCC in Troy will serve patients on Tuesdays and Thursdays from noon to 5 p.m. Teresa Hunsucker, R.N., will continue her current role as Montgomery Memorial’s transitions nurse for advanced heart failure and Emergency Department patients while also coordinating services for the new clinic.
In addition to FirstHealth services, she will also be able to connect patients with appropriate non-hospital resources.
“We want to make lowly motivated patients become highly motivated patients so they become better self-managers,” Elliott says.
According to Beth Walker, president of Montgomery Memorial Hospital, patients will be seen in a TCC within 48 to 72 hours of their discharge from any FirstHealth hospital. Referrals can be made by either a hospitalist or emergency department physician.
Each patient will be assessed for a variety of services that include health coaching, medication assistance, respiratory therapy, home health, behavioral care and tobacco cessation to make sure they are on track with their prescribed plan of care.
“Our goal is to keep them from going to the emergency room or being readmitted to the hospital,” Walker says.
While all hospital-discharged patients are eligible for the 30-day service, patients with chronic disease will make up the targeted population and the primary care provider will always be a member of the health care team.
Walker predicts the TCC program will ultimately benefit the entire community as primary care professionals become educated on the transition care model and begin offering transition-type services in their offices.
“We want to change the way health care professionals work with patients,” she says.
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