Facilitating Transitions and Reducing Hospitalizations

 Care Coordination 

Visiting Nurse of Somerset Hills, Basking Ridge, New Jersey.
Agency Description:
Since 1904, the Visiting Nurse Association of Somerset Hills (VNA) has been providing much needed home health and hospice care, adult day services, and wellness programs to their community. It all began when parish nurse Miss Lillian Nichols offered her nursing services to the sick and poor of Bernardsville and surrounding towns. A committee formed to direct the nurse and be responsible for her services to the community of Somerset Hills, including the towns of Bernardsville, Basking Ridge, Gladstone, Mendham Borough, and Chester Borough. In 1906, this founding committee was incorporated as the Visiting Nurse Association, one of the first 100 such organizations in the United States.

Over the decades, the VNA organization, range of services, and service area continued to expand to meet the growing need for patient-centered and quality-focused home and community health care.

The mission of VNA of Somerset Hills and its subsidiaries is to provide individuals and families with comprehensive, high quality, cost-effective home and community health care services, regardless of ability to pay, using partnerships where appropriate. 
Population Impacted:
Patients with surgical wounds. 
Strategic Partners:
Employees of VNA of Somerset Hills.
Project Description:
Hospitalizations are costly and stressful. Medicare is working to decrease preventable rehospitalizations by imposing penalties on hospitals. Home care agencies play an important role in helping hospitals decrease rehospitalizations. According to the CDC, in 2011 there were an estimated 722,000 health care associated infections resulting in approximately 75,000 deaths. The most common infections included surgical site infections, estimated at 157,000 infections. With the introduction of total knee/hip arthroplasty as a penalized diagnosis, it is important to educate clinicians on preventing rehospitalizations in surgical wound patients.

Interventions focusing on transitioning patients between settings have shown reductions in the number of patients re-hospitalized. Clinicians received formal education on care transitions based on the HHQI Best Practice Intervention Package, Cross Settings 1. Hospitalizations in a one-month period were compared pre- and post-education.
The number of rehospitalizations related to surgical wounds in June 2014 (n=28) was compared to June 2015 (n=17). The number of rehospitalizations decreased from 14.3 percent in June 2014 to none in June 2015. While there was a reduction in the number of hospitalizations, the findings were not statistically significant.
Outcome Measures:
Transitions in care help to decrease the number of rehospitalizations. This care coordination program continues to grow with total reductions in hospitalizations. New outcome data will be available in 2017. 
Barriers to Implementation:
The barrier to implementing this project is the availability of the staff nurses for the education programs. The ability to reach all staff nurses is dependent on the demands of the patients on the specific days of the education and the work schedules of the staff nurses, as the nursing staff is comprised of full-time, part-time, and per diem staff who do not work every day. If on the day of the planned education there is an influx of admissions, or a need for urgent patient visits, not all staff nurses will attend the education program.