Dear Colleagues,
I hope the summer season finds you well.
Our entire health care team, with our community partners, continues to seek new and effective care protocols for chronic disease management. As you know, among the more challenging and prevalent chronic diseases in our five-county region are congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia. In collaboration with Cardiology, Pulmonology, Cardiology, Hospitalists and Emergency Medicine colleagues, we have put into place care treatment protocols for patients with these conditions who present to our Emergency Departments. Our hope is that these protocols will reduce our Potentially Avoidable Utilizations (PAUs) and Readmissions while also ensuring high value, high quality and effective care.
We are now initiating a second phase of this effort, which is a new pilot program designed to help patients who present in our emergency departments and/or become hospitalized with these conditions experience a safe and appropriate transition to care back into their homes or other community settings.
Central to this pilot program is the creation of new position called “transitional nurse navigator” (TNN). One TNN will be based at UM Shore Medical Center at Dorchester as of mid-July; the other will be on-site at UM Shore Medical Center at Chestertown beginning in early August. Each TNN will be dedicated to CHF/COPD/pneumonia patients who are deemed at high risk for readmission. TNN duties include:
- Coordinating appointments with primary care providers and specialists for affected patients after hospital or Emergency Department discharges
- Facilitating the transfer of patients’ post-discharge care to appropriate medical providers and/or residential care facilities (skilled nursing, assisted living, etc.)
- Following up with patients via telephone (and in some cases, via in-home visits) for up to 30 days after discharge
- Providing education and support to patients and their family members and/or caregivers that will improve health literacy and understanding of their disease management
- Completing medication reconciliation for the patient
Going forward, we hope that the model established by this pilot program can be applied to all care locations and diagnoses to help UM Shore Regional Health decrease potentially avoidable utilization, including hospital readmissions and repeated visits to the Emergency Departments, while also improving our effectiveness and efficiency in treating high-risk patients.
As always, if you have any questions, comments or concerns, please do not hesitate to contact me. In the meantime, please know that you have our deep appreciation for all you do to help UM Shore Regional Health realize our vision To Be the Region’s Leader in Patient-Centered Care.
Sincerely,
William E. Huffner, MD, MBA, FACEP, FACHE
Chief Medical Officer, Senior Vice President – Medical Affairs
219 S. Washington Street
Easton, Maryland 21601
Phone: 410-822-1000, ext. 5867
Fax: 410-822-2147
Email: whuffner@umm.edu