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Bridges UW Health Transitions of Care
Community Partner Corner 2
Finding TC Notes in Health Link 2
Surgical Transitions Program
Kudos from Our Patients
3
3
Need a TC Consult? 4
Hearing Aid Fairy
Patient Satisfaction Survey
5
5
How FITbit are You?
Transitions Program Outcomes
6
6
Volume 6 Spring 2016
Transitioning to the Community
elcome to the spring 2016 Bridges Newsletter. This newsletter is meant to keep
you informed of the activities surrounding Transitions of Care at UW Health,
and as always, we have a lot going on!
A “transition” occurs each time there is a handoff of the patient and his/her health care
information. This handoff could be to another unit, another provider, or another level of care. In
order for the transition to be successful we need engaged providers, staff, patients and
families along with meticulous documentation and transference of clinical information. Most
importantly we need to assure that the patient and his/her caregiver truly understand what is
required of them to succeed during and after the transition. This is most notably done via the
“teach back” method, which is in essence, a “verbal” return demonstration by the patient/
caregiver.
A safe transition also necessitates assuring that our patients are appropriately supported in
place once they are back in the community. UW Health can’t do this alone so we are actively
collaborating with our community partners to ensure that we enlist their services and areas of
expertise. Towards these efforts, UW Hospital currently hosts three different community based
Transitions Coalitions (1) Skilled Nursing Facility (2) Assisted Living Facility and (3) Dane
County.
In this newsletter we begin our feature called the “Community Partner Corner” in which one of
our community partners will share their thoughts on the coalition and safe transitions. Darian
Dalsen has been an active member of our Dane County Transitions Coalition and has
commented multiple times that his participation in the Coalition has resulted in multiple quality
improvement initiatives at his agency. Please be sure to read his column.
As always, feel free to call or email me if you have any questions, comments or thoughts
regarding our transitional care efforts here at UW Health.
Happy Reading,
Maria Maria Brenny-Fitzpatrick DNP, RN, FNP-C, GNP-BC Director Transitional Care University of Wisconsin Hospital
“They may FORGET your name, but they will NEVER FORGET how you made them feel.” ~ Maya Angelou
Transitions Initiatives
Surgical Transitions team
expands to Surgical
Trauma Services April,
2016. See article p.3
Transitions Coordination
Committee serves as a
major collaborative ven-
ue for coordinating tran-
sitional care initiatives.
The committee consists of
representatives from
Inpatient ED, Outpatient
Family Medicine, Unity
Health, Pharmacy, Pa-
tient Resources, Complex
Case Management, RN
Care Coordination,
Learning Center and
Population Health.
Inside this issue:
Bridges~UW Health Transitions of Care Page 2
Community Partner Corner Darian Dalsen, Community Liaison Director
How to find Transitional Care Program Notes in HealthLink
Comfort Keepers provides in home care. We can provide 1-24 hours a day assisting with light housekeeping, activ-ities of daily living and social activities. We can work with individuals who have Alzheimer's, Parkinson's and have complicated health conditions. I have been a member of the Dane County Community Coalition for two years. I joined the coalition to assist the hospitals reduce re-admissions. I wanted to make a difference by being part of a group that was going to have a direct impact on healthcare in our community. I initially thought the work I was going to do was going to help the hospitals, however what I learned was that the information I obtained from the coalition directly impacted our cli-ent’s health and directly reduced the need to go to the hospital. We improved our training to caregivers and clients on CHF, improved communication with physicians, physical therapy, and hospice related to changes in medical con-ditions and increased education on medication management. We have also started attending medical appoint-ments and follow up assessments completed by our RN and reported to all medical providers. I like being part of the coalition because I have learned about additional resources to help clients and families. One of the biggest benefits has been developing relationships with companies to help improve health care out-comes of people we are serving in the community.
NEW - Surgical Transitional Care Program Kris Leahy-Gross MSN, RN
Transitions of care occur each time the patient moves from one health care provider or health setting to another. These care transitions are the highest risk phases of care for patients and may result in preventable readmissions. With the proven success of the UWHC Medical Transitional Care program (utilizing the Coordinated-Transitional Care (C-TraC) model), we implemented the Surgical Transitional Care Program in October 2015. The C-TraC model is an evidence-based transitional care program which uses telephone-based outreach to improve care transitions of patients and reduce 30-day rehospitalizations. Patients enrolled in the Surgical Transitional Care (STC) program must have a working telephone and are discharging home. Clinical criteria include any adult undergoing the following: pancreatectomy, gastrectomy, emergent small bowel resection, bowel perforation, new ostomy, drain upon discharge, pre-discharge infection or any other major complication. Additional characteristics used to prioritize the caseload include: lives alone, caregiver not identified, recommended level of support declined (e.g. home health), discharged to home with home health, post-operative delirium or cognitive dysfunction, dementia and/or age ≥ 65 years old.
The STC program consists of 2 registered nurses and a social worker who identify patients at risk for rehospitalization. Patients enrolled in the STC program receive follow-up phone calls for 3-6 weeks post-discharge utilizing the Coordinated-Transitional Care model. Emphasis is placed upon patient-led medication reconciliation, patient education with identification of 3 red flags, post-discharge follow-up with surgeon and/or PCP, and addressing a cadre of other patient issues. The program staff works closely with providers, ambulatory and inpatient nurses, coordinated care staff and other clinical supports to determine discharge goals and assure coordination of care. After discharge, the team works with the patient and family, caregivers, medical team (MD, NP, PA), home health and other providers as needed to coordinate care. Outcomes From 10/12/15 through 2/29/16, the STC program enrolled 158 patients. Ninety-six percent (n=151) of the patients engaged in the C-TraC protocol. Of the patients engaged in the transitional care protocol, 12.6% (n=19) readmitted within 30 days of index admission. A benchmark is being established by surgical department researchers. Based upon early program data (10/12/15 through 1/10/16) patients were in the program for an average of 21.3 days with an average age of 57 years old. During the post-discharge telephone medication reconciliation, 30% of patients had at least one medication discrepancy.
Emily Osterhaus BSN, RN, CMSRN Nurse Clinician—Surgery
Laura Sell MS, BSN, RN Nurse Clinician—Surgery
Kudos from Our Transitional Care Patients
“Positively impressed with the whole program. I was glad Heather followed up after her visit.” ~ Leroy
“Great for people who have holes in their thinking.” ~ Sylvia
“Wonderful idea - very good program.” “Really, really helps people like me who don't pay attention to their health.” ~ Joanne
“Excellent! Extraordinary program!” ~ Marcia
“Very happy customer - glad to know there’s a support system in place.” ~ Donald
“Program is great for some people, especially if they live alone it would be a comfort factor.” ~ Russell
“Wish every hospital had this program.” ~ Carol
Page 3 Volume 6
Bridges~UW Health Transitions of Care Page 4
Does My Patient Qualify for a Transitional Care Consult?
How to place a consult
The Medical and Surgical Transitional Care Programs are designed to target vulnerable patients who are at a high-risk for negative post-hospital outcomes. Core program enrollment criteria include patients discharged to home or assisted living facility and have a functional telephone. Additionally, program enrollment is prioritized based upon the following patient conditions: lives alone, inadequate sup-ports, caregiver not identified, hospitalized in preceding 12 months, documentation of dementia, delirium or other cogni-tive dysfunction, recommended support declined (e.g. home health) or clinical judgment. Consults can be entered via Health Link. Medical Transitional Care Program Core Enrollment Criteria:
60+ year old patients on the general medicine, hospitalist, cardiology and family medicine services
ACE consult patient referred by ACE team Surgical Transitional Care Program Core Enrollment Criteria: Post-operative patients on the General Surgery (blue or orange service) or Emergency General Surgery (red service) with the following:
Pancreatectomy
Gastrectomy
Emergent small bowel resection
Bowel perforation
New ostomy patient
Drain upon discharge
Pre-discharge infection or any other major complication
Program enrollment exclusions: Excludes patients with primary diagnosis of:
ETOH/Substance withdrawal/overdose
Psychiatric
Scheduled cardiac procedure admit Excludes patients:
Care WI
Central Wisconsin Center
UW Health's Complex Case Management
Patient with case/care manager such as Transplant Coordinator, CHF Coordinator, WDI SW/CM
Active chemotherapy
Hospice/palliative care
Prisoners
Maria for obtaining her Doctorate degree! ~ Maria Brenny-Fitzpatrick, DNP, RN, FNP-C, GNP-BC
Peggy for obtaining her Geriatric certification! ~ Peggy Troller, MSMFT, BSN, RN-BC
Kris Leahy-Gross, MSN, RN, CPHQ ~ 2016 Nursing Excellence Award Nominee
Congratulations!
One third of people over 65 years and one half of elderly people aged 70 and over are serious-
ly affected by severe hearing limitations caused by demographic and environmental factors.
(Ligenau et al)
For the increasing number of hearing impaired patients at the hospital it is very important to assure
an undisturbed communication and interaction with the hospital staff and it is essential to avoid mis-
understandings and shortcomings caused by hearing limitations. (Ligenau et al)
Did you know one of the reasons patients don’t seem like they understand you or the instructions they are being given is
because their hearing aid battery is dead? But thanks to our very own hearing aid battery fairy Peggy Troller, Transi-
tional Care RN, patients will be able to hear more clearly!
Being a wearer of hearing aids herself Peggy realized the growing need of pts in the hospital whose batteries were
weak or dead so she reached out to Friends of UWHC for a grant to purchase batteries to provide to these pts. If you
have a patient in the hospital that is struggling to hear you check their hearing aid battery and if they need it replaced
contact Peggy at 890-7248 or pager 1587.
Lilgenau, Anneliese, Mag., and Mag. Janna Mayer, MD. "The Perspectives and Experiences of Hearing Impaired." Fac-
ulty of Social Sciences Department of Nursing Science (n.d.): n. pag. Web. 4 Mar. 2016.
Page 5 Volume 6
University Hospital’s Very Own Hearing Aid Fairy
Patient Satisfaction Survey—A Year in Review
228 pts contacted from January 2015 to December 2015 / 207 completed the survey (91%)
Yes No % Yes
Satisfied with the Transitions program 207 0 100
Program provided confidence to talk w/ provider* 178 0 100
Program provided support for new problems or issues* 173 0 100
Helped pt understand how to improve health** 191 3 98.5
* Respondents whose answers were categorized as NA:
29 stated they already have a good rapport with their physician and feel comfortable talk-
ing to them about anything.
34 reported they did not have any additional problems for which they needed support.
** 3 respondents felt the program didn’t affect their understanding of how to improve their health.
Strongly Disagree Disagree Agree
Strongly Agree
Felt the Transitions program was helpful 0 0 91 116
Would recommend the program to others 0 0 68 139
Found social work involvement helpful 0 0 6 10
Know who to contact for future needs 0 0 8 8
Transitional Care Program Outcomes
Control Group is defined as UWHC patients 60 and older, discharged to home or an assisted living facility, in the family practice, hospitalist, cardiol-ogy, or family medicine service lines and NOT enrolled in the Transitions of
Care Program.
Transitional Care Steering Committee Key Contacts
Maria Brenny-Fitzpatrick, DNP, Director, Transitional Care
Elizabeth Chapman, MD, Physician Lead
Mark Sanderfoot, Business Planning & Development
David Hager, PharmD, Pharmacy Administration
Questions or comments about Transitions of Care?
Contact Maria at
Bridges~UW Health Transitions of Care Page 6
Total Program Results: July 2014—October 2015
Clinical Service TCP Readmis-
sions Control Group Readmissions
TCP Dis-charges
Control Group Discharges
TCP Readmis-sion Rate
Control Group Readmission
Rate Difference: TCP-UWHC
FAMILY PRACTICE 11 25 133 153 8.3% 16.3% -8.1%
HOSPITALIST 52 121 442 672 11.8% 18.0% -6.2%
CARDIOLOGY 19 58 309 394 6.1% 14.7% -8.6%
GENERAL MEDICINE 38 68 347 298 11.0% 22.8% -11.9%
TOTAL 120 272 1,231 15,17 9.7% 17.9% -8.2%
Statistically significant difference: p<.10 p<.05 p<.01
How FITbit are You? Peggy Troller, MSMFT, BSN, RN-BC
The Transitional Care staff places a high priority on working together as a close-knit team. One
way we build our team cohesiveness is by regularly adding a little fun to our work.
Recently, TC team members have started occasional Fitbit Workweek Challenges. Many of the team members use a Fitbit
to track their daily steps and we invited each other to join in friendly competition from 12:01 AM Monday to midnight
Friday. The competition was fierce, with the top spot changing hands several times throughout the week.
The winner of the first challenge was Kris Leahy-Gross with over 68,000 steps, for which she won a lovely blue ribbon
and bragging rights - until the next competition.
Get moving and challenge your co-workers!
Check us out on the web: http://www.uwhealth.org/transitional-care/transitional-care/42062
