Patients are vulnerable when being transitioned from one care setting to another. The Transitional Care Program at Cortland Regional Medical Center addresses potential risks associated with patient transitions by using concepts and tools from well-known programs, such as the Care Transitions Intervention ™ and Project RED (Re-Engineered Discharge). The program's goal is to reduce readmissions for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease within 30 days of their discharge.
A Registered Nurse Transitions Coach facilitates interdisciplinary collaboration and care continuity and encourages patients and caregivers to participate in care plan execution. The coach also partners with staff from a nearby cardiology office that provides early interventions to prevent emergency department visits and potential admission. Home healthcare nurses visit patients at home within 72 hours after discharge to answer questions and assist with future appointments.
More than 460 patients have been offered participation in the program; 86% of those accepted. Over the course of one year, 30-day hospital readmissions for CHF patients decreased to 14.3%. The 30-day readmission rate for the CHF patients in the program was reduced from 50% to 12%.