October 5, 2017
Dear Colleagues:
As you know, addressing population health issues has become an increasingly important priority in hospitals and health care systems nationwide. At UM Shore Regional Health, we are implementing new strategies to improve care across the continuum – from the moment a patient is treated in one of our emergency departments or admitted to an inpatient unit, through discharge and back into their homes and outpatient care settings.
One of these new strategies is our Care Transition Rounds (CTR), which began in late spring. CTR is now in full swing in our three hospitals: Every weekday, every patient under the care of a hospitalist – is “rounded on” by a comprehensive team that includes hospitalists, nurses, case managers and social workers as well as staff from pharmacy and rehabilitation services. The format of UM SRH Care Transition Rounds is highly structured, creating greater uniformity and accuracy in the assessment of 125 to 135 patients daily.
We are finding CTR to be an excellent tool for enhancing patient care and creating more comprehensive and successful discharge plans. The benefits of CTR to our patients include improved quality of care; better consideration of their appropriateness for alternative therapies; reduced length of hospital stay; reduced likelihood of readmission; and smoother transitions of care.
Another major population health strategy now in progress at UM Shore Regional Health is the Transitional Nurse Navigator (TNN) initiative, which was introduced in the June 2017 issue of PulseCheck. This program proved to be of value almost immediately and has since been expanded from two TNN positions to four – two working from Shore Medical Center at Easton and one each from Shore Medical Centers at Chestertown and Dorchester.
The TNN initiative also now benefits a wider range of patients. While the nurse navigators’ original focus was on patients diagnosed with COPD/CHF and pneumonia, they are now serving patients in treatment for any chronic disease that increases the likelihood of emergency care visits or hospital readmission. Our TNNs work closely with patients and family members, primary care providers, home health and rehabilitation care providers, and residential care facilities to enable patients to achieve and maintain their best possible health outside the walls of the hospital.
I am grateful for the tremendous commitment, creativity and attention to detail that our hospital leadership, our clinical teams and case management teams, and Shore Bayy Hospitalists, LLC have invested in the development of these and other important population initiatives. As always, I welcome ideas and input from all of you who are helping UM Shore Regional Health achieve our mission of Creating Healthier Communities Together.
Best wishes for an enjoyable fall season!
Sincerely,
