Improving transitions in care has been a significant focus of my work for a number of years as home care – and now all of health care – aims to reduce avoidable hospitalizations.  When we started our journey at VNSNY, we searched long and hard for tools, interventions and guidance about transitions.  After collecting and reviewing the literature, our mission was to find the most suitable tools to support safe patient transitions, and to embed them in our organization’s care standards. Then, a number of our clinical teams tested these tools and interventions. Now the best in transitions tools, interventions and practices are compiled in CHAMP’s new Geriatric Care Transitions Toolkit (and this treasure trove of information is accessible with only a few clicks!)

One team’s test
In an early experience, one team tested a “Red Flags” tool to prevent an ED visit and/or hospital admission through early detection of deterioration in a patient’s condition (click here to see “My Action Plan,” as we called it.  Plus there’s another “Red Flags” tool, “My Emergency Plan,” in the CHAMP Toolkit).   Many of the patients on their team were older adults who lived alone and were at high risk for rehospitalization.  When they came home from the hospital, despite being relieved to have made it through their front door, they were often exhausted and had limited ability to absorb all the interventions and guidance aimed at keeping them safely at home.  These nurses asked “How could patients, especially those who were alone and overwhelmed, be helped to know when to call for help, especially since the nurse was only intermittently present in the home?”

Involvement of the Home Health Aide
The team’s test started with their patient, “Mr. J”:

Mr. J. was a 78 year old patient admitted to home care after a hospitalization for an exacerbation of heart failure.  This was his third admission in the past six months.  Mr. J. lived alone since his wife died five years earlier.  He was fiercely independent, minimized his need for assistance, and told the nurse his goal was to remain in his home.  However, after this hospital stay, Mr. J. was physically weaker and reluctantly accepted the service of a Home Health Aide (HHA) until he regained his strength.  The nurse used Mr. J.’s goal in a discussion about how the HHA would help him carry out his personal care activities but also help him learn how to be alert to when he might need to call the doctor or nurse, so he could remain home – out of the hospital.  During the episode, as the nurse taught Mr. J. about his medications, and monitored his symptoms and his weights, the HHA was involved in those sessions, preparing to coach Mr. J. in observations about his condition, or how he was feeling with his medications.

This led to the creation of the tool, “Home Health Aide Action Steps to Reduce Hospitalization” (also in the CHAMP Toolkit)  The nurses on the team tested and refined the questions as they worked with HHAs to coach patients to be alert to signs and symptoms and get help before it became necessary to call 911.  The testimony to the success of optimizing the role of the HHA was a patient who with the help of the HHA noted her symptoms, and called the nurse who was able to intercede with changes to avoid a hospitalization.  The patient told the nurse, “my home health aide didn’t mop the floor, but she saved my life!”

Resources in CHAMP’s Geriatric Care Transitions Toolkit that include the broader patient care team (such as paraprofessionals or family caregivers) can be particularly beneficial to improving transitions in care. The network of people around the patient can be a “safety net” for patients, and help in promoting safe transitions.

Sally Sobolewski
Director, Practice Improvement
Visiting Nurse Service of New York