Integrating Care to Help Patients Stay at Home, Sweet Home

Jennifer Laffey, RN, NP

Northwell Health hospitals are a great place to work, but no once wants to live there. That's why a cadre of nurses is helping patients to avoid unnecessary returns to the hospital.

Reducing costly, unnecessary readmissions not only helps patients recover at home, where they are most comfortable, but also provides hospitals incentives from the US Centers for Medicare & Medicaid Services.

“The health care field can no longer afford a ‘silo’ approach to treating patients,” said Geralyn Randazzo, RN, vice president of care coordination for the health system. “Integration is crucial across the continuum of care.”

For examples of integration at work, consider the nurses who follow up with patients after discharge for Health Solutions, Northwell’s value-based care-management arm. They reduce readmission rates among high-risk patients by coordinating care and streamlining communications between clinicians, patients and caregivers. Using specific protocols, they follow up patients recovering from an acute health episode for 30 days. Patients with multiple chronic conditions get up to nine months of support after discharge, if necessary.

Debby Quail, RN, care manager, helps patients with commercial insurance after their discharge from LIJ Medical Center, Southside Hospital or Huntington Hospital. She calls within 24 hours to check their progress, ensure home care services are in place and facilitate scheduling of followup doctor appointments within seven days. If patients are at very high risk for readmission, Ms. Quail visits them at home within 72 hours to assess their situation.

Increasing health literacy goes a long way toward decreasing readmission rates. “The goal is to help patients and/or caregivers understand their condition, medication and treatment, so they can manage the condition,” Ms. Quail said. “One of my biggest challenges is building relationships with patients and gaining their trust so I can better engage them in their own care.”

Similarly, care navigator Jennifer Laffey, RN, NP, works to build patient trust with post-operative cardiac surgery patients on Medicare. She visits them at home 48 to 72 hours after discharge from North Shore University Hospital.

“Teaching patients what is normal in their recovery and how to manage their fear can prevent them from returning to the hospital,” Ms. Laffey said. If problems arise, she can speed relief by prescribing medication in collaboration with the physician responsible for the patients’ plan of care. Ms. Laffey said she also has the flexibility to “sit with a patient for two hours to provide the tools and education the patient and caregiver need to manage their care.”

Clinical issues aside, clearing socioeconomic hurdles is frequently a challenge. “Many patients are trying to recuperate while also trying to care for a loved one who may be chronically disabled or ill, too,” Ms. Laffey said. Though she can arrange for transportation, medication assistance, housing resources and other social supports if necessary, “some patients still have so many challenges.”

Ms. Laffey said that patients do not want to return to the hospital. She added, “They almost see it as a failure — that something went wrong or they didn’t do something right.”



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