Cooper has established a new Transitional Care Department to provide our patients with the right care in the right setting. The Transitional Care Department is comprised of a physician, inpatient social workers and home-health nurses, as well as its newest members: advance practice nurses and health coaches. Inpatient social work and home health will continue to focus on timely transitions for patients leaving the hospital with services including acute and subacute rehabilitation, visiting nurses, durable medical equipment, as well as many other patient-centered needs.
The new nurse practitioners and health coaches serve the needs of medically and psychosocially complex patients during the transition from an inpatient hospital setting to the patient’s community setting to improve outcomes and reduce frequent hospital readmissions. The service utilizes motivational interviewing in combination with education and coaching to help our patients meet their patient-centered goal. High-risk patients for this service are identified through predictive analytics.
“Our team provides critically needed support and coaching at the most vulnerable time for our high-risk patients—during the “hand off” or transition between settings of care,” explained Susan Coutinho McAllister, MD, Medical Director of Care Management at Cooper, who will oversee the department. “The services will provide a bridge that will complement the patient’s primary care and are designed to avoid preventable poor outcomes during a challenging time following hospital discharge.”
To ensure that there are no gaps in care, transitional care begins following hospital admission. Beginning very early in the hospital stay, the team will conduct a comprehensive assessment for readmission risk including health literacy, polypharmacy, principal diagnoses, and psychosocial co-morbidities. The team will devise a risk-specific intervention plan for each patient focused on meeting the patient’s goal.
By continuing to educate and coach patients to self-empowerment during the healing process, the team can help each patient avoid unplanned hospital readmissions and emergency room visits for primary and coexisting conditions.
“Studies have shown that hospitals that have implemented transitional care models not only improve outcomes, but also reduce cost while improving patient and family satisfaction,” said Dr. McAllister. “This is another way we are improving the Cooper experience for those we serve.”
The team coordinates with health professionals in other disciplines and departments as well as outside agencies and resources as needed to provide a comprehensive plan of care once the patient is ready to transition from the hospital to home or their next care setting.
Wendy A. Marano
Public Relations Manager