Transitional Care nurses in Bennington…catalysts for integrated care delivery in their community. By Billie Lynn Allard

At Southwestern Vermont Health Care, located in Bennington Vermont, we have been on an exciting journey for the past 3 years as we seek ways to improve the health of our population. As healthcare reform continues to evolve, the shift from inpatient care delivery to outpatient has provided an opportunity for us to consider shifting acute care resources to meet individuals where they are now.  In 2013, a group of three Clinical Nurse Specialists stationed in the Intensive Care Unit, Telemetry Unit and Emergency Departments attended a Transitions of Care training program at the University of Pennsylvania based on the successful research of Mary Naylor, PhD, RN and her team.  Since that time, all primary care practices in our community have partnered with Transitional Care Nurses (TCN), identifying high risk patients with chronic diseases and assisting with education, symptom identification, and medication management.  The nurses met with community partners to identify where there were gaps in care, communication, coordination and available resources. Our goal was to improve integrated care delivery for the population we serve avoiding duplication or competition. Expert clinical nurses navigating with patients and their families from one care setting to the next could clearly identify opportunities for improvement.  Over the past three years with support from hospital leadership and Vermont Health Care Innovation Project grant funding, we have been finding creative ways to bridge the gaps for our community.  A Community Care team composed of clinical partners, and community agencies that assist frequent users of the Emergency Department with mental health and addiction, meets monthly to discuss specific patients who have consented to participate in this collaborative approach to care.  These patients seeking care sometimes three times per week are not appearing to get their needs met and often may be better served by assistance with finding employment, safe housing, adequate food and social support.  Having all partners at the table has been pivotal in our collective ability to help this population of patients’ live healthier, happier lives.  An added bonus has been the development of strong relationships and improved understanding of the role we each play and the recognition that we can be so much more effective as a team than we are as individuals.

Hospital based nurses now functioning across the care continuum have a renewed appreciation for the reality in long term care and rehabilitation settings and at home and in provider office settings. Suddenly we recognize how little care is delivered in the hospital setting and how much more happens outside of our walls.  Patients do not understand their discharge instructions, are overwhelmed and confused about their medications and many need food, water and shelter before they can even begin to learn about managing their chronic disease.  The stark realization of the role of social determinants of health is clear and the urgent need for a community social worker to assist with helping individuals get connected with the right resources to meet their needs.  Our vision includes the creation of community network of integrated social workers handing off to one another, assuring necessary steps are taken for health care coverage, safe housing and access to medications, heat and food.

On this journey, we see clearly the challenges of primary care providers, as they manage large panels of patients, with limited time and resources. Medical Home implementation has been a huge source of support in our community and we have partnered with them to see how we can best collaborate and work together.  Primary care providers requested access to clinical pharmacists that could assist them with medication management, reconciliation and consults related to polypharmacy.  Clinical pharmacists have partnered with four practice settings on a pilot project to be one more resource for patients and providers and assure improved medication adherence and understanding.  They may see patients in the hospital, primary care office or even at home.  Clinical pharmacists now have the advantage of witnessing what the challenges are outside of the hospital….in the real world.

In 2013, a pilot project was initiated in one medical home practice, embedding a Certified Diabetes Educator (CDE) nurse to see patients in the office to assist with education and management of their diabetes with promising results. This program expanded to other practices with evidence of decreased A1C results as well as patient and provider satisfaction.  In March of 2016, we expanded this program to include an additional CDE who is available to partner with other provider offices and see patients as well as being available for consultation at the hospital and skilled nursing facility.  Creation of an integrated diabetes team includes dieticians and certified diabetes educators seeking to improve the health of our population.  A year- long pre-diabetes program sponsored by the YMCA is underway with enthusiastic participation from community members.

At Southwestern Vermont Medical Center, our rate of readmissions coming from skilled nursing facilities was higher than benchmarks. The Transitional Care team looked for evidence based practice on what might help and found INTERACT ™.  This system of empowering nursing assistants to speak up when they notice subtle changes in condition, report them to nursing who then reports them to a physician or nurse practitioner, can have a major impact on managing patients at the Skilled Nursing Facility (SNF) without transfer to the hospital.  A Stop and Watch process to assess certain patients more frequently with documentation in the medical record and updates to the plan of care can also positively impact meeting regulatory requirements.  Our experience includes sustained decreases in readmissions from our affiliated SNF and are leading implementation in all of the other facilities in our service area.

One by one, we are looking beyond the hospital walls and bridging gaps in care coordination in our community. We all concur that it is the most rewarding and exciting work of our careers.  We are meeting the triple aim as we have decreased hospital admissions by 68% and ED visits by 29% for the patients before and after TCN services, thus decreasing the cost of care. Standardization of COPD, CHF and Diabetes care is improving quality outcomes demonstrated by pulmonary rehabilitation statistics and AIC levels. Patient surveys show that our patients and their families appreciate the support of this program and have an improved understanding of their illness and medications.

Quarterly meetings have been scheduled to assess our progress and chart the course for the future. Expansion of who is at the table continues to evolve as layer after layer is uncovered.  A recent community forum was encouraging as town leaders, legislators, educators, and representatives from across our community came together and listened to a panel discussion of what is happening right now.  We feel blessed to be in an environment open to change, excited about innovation and determined to continue down this journey of creating an accountable community.  We feel fortunate to be involved with the Accountable Communities for Health teams from across the state of Vermont, who are on this same journey. The opportunity to network with them, build relationships and benefit from their lived experience in their community is priceless.  We are happy to share our lessons learned with others as we lead this country in a positive direction, focused on improving the health of our citizens.






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