CRMC begins new program to help patients to say out of hospital

Posted By | July 29, 2016 6:52 am

Last Updated: July 29, 2016 at 6:55 am

Lynda Richardson

Lynda Richardson

Jason Hutchnes

Jason Hutchens

Cookeville Regional Medical Center is introducing a new “transitional care” program to assist hospitalized patients with illnesses and conditions that put them at risk of multiple admissions to the hospital.

The Transitional Care Program is designed to help patients admitted to the hospital with illnesses such as chronic obstructive pulmonary disease, congestive heart failure and pneumonia to transition back to home and help them manage their illness to reduce the high risk of readmission to the hospital. The program will provide them a stair-step transition between hospital and home.

“Complex illnesses like these can be difficult to manage at home, and as a result, patients often end up back in the hospital within a short period of time,” said Lynda Richardson, RN, transitional care coach at CRMC. “With this new program, our goal is to provide patients with the tools and support they need to transition back home and stay better longer so that they don’t need to come back to the hospital anytime soon. We will help patients learn more about how to manage their disease.”

As part of the 30-day program, patients at high risk of readmission will receive a visit from a transitional care coach while they are in the hospital as well as three follow-up calls over the next four weeks from their coach once they arrive home. Patients will also be referred to the clinic during the time (3-5 days) between their hospital stay and their follow-up appointment with their doctor. Under the direction of a pharmacist, the clinic is available to help patients better understand their medications and the role they play in managing their illness.

“When you have a complex condition like COPD or congestive heart failure, understanding your medications and how to take them correctly plays a huge role in whether you are readmitted to the hospital,” stated Dr. Jason Hutchens, Pharm.D., lead pharmacist in the Transitional Care Clinic. “We want to be sure that the patient understands and follows their discharge plan. It’s very common for patients to become confused with their discharge instructions especially in regard to changes with their medications. Sometimes patients won’t fill their new prescriptions due to high cost. If we can catch this early on, we can hopefully help them find more affordable options.

“We want to help these patients as much as we can,” continued Hutchens. “No one enjoys being in the hospital so we are doing all that we can to help patients feel better longer term and help them avoid additional hospital stays.”

Benefits of the new program to the patient include increased knowledge and confidence in managing their disease as well as assistance with managing their medications. They will also be coached in knowing early warning signs and when to call their doctor. The program will encourage patients to keep their follow-up appointments with their primary care provider.

For primary care physicians and providers, the program will provide follow-up communication on each patient seen in the Transitional Care Clinic to provide continuity of care and easier management of patient medication lists.

“I am certainly appreciative of this new program,” stated Ernest Buchanan, M.D., family practitioner and president of the CRMC Medical Staff. “Education, awareness and compliance by the patients in managing their condition are among the keys to their overall health and long-term wellness. The transitional care program will be highly beneficial for patients with complex diseases.”

The services of the Transitional Care Program are available at no additional cost for the patients.

“Not only does this program benefit the patients in learning more about their disease, but it also helps reduce healthcare costs overall, for both the patient and the hospital,” said Buffy Key, CRMC’s Vice-President for Quality Improvement. “It’s a win-win for all of us. Reducing hospital re-admissions is an important initiative nationwide.”

The new Transitional Care Clinic is located inside the hospital’s Registration Department in the CRMC North Tower Main Entrance and may be reached by calling (931) 783-5895.

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