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Message from Leadership: Update on Transition Care Teams

Published September 15, 2014

By Kim Williams, Chief Operating Officer

On July 22, our process for patient transition changed. Any change is difficult, but a change that actually transforms our jobs, the place we call home, and our team is very difficult.  I would like to recognize the members of the transition planning teams for their resilience and commitment to their patients.  It is safe to say that every member of the inpatient care delivery team at Colby Campus has experienced changes in workflow and communication as we have moved through these past six weeks. Learning new processes and roles is challenging when you are an experienced clinician because it’s unfamiliar. Change makes us feel like a novice again and it is easy to slip back into old roles and believe that the old way was “better” because it was more comfortable.

One thing remains true: our goals have not changed since we started this project. Our goals have always been to decrease the number of contacts for patients, create an efficient transition process for patients post-discharge, and decrease readmissions by providing accurate follow-up with experienced clinicians. Feedback we have received from our community partners in the past suggested we were not doing a good job transitioning patients from our hospital, particularly with medically complex patients. In order to provide our patients with better follow-up care, we created four new teams to help with the transition process:

  • Transition Coordinators assist Cardiac Surgery and Total Joint Surgery patients
  • Transition Planning MSWs help manage patients that will require a change in care setting—nursing homes, SNFs, Rehab, etc.
  • Transition Planning RNs manage medically complex patients discharging to home
  • Transition Associates support staff that will allow MSWs and RNs to work at top of license

In addition to creating these teams, we have established a community wide standard on post discharge follow-up with a color coded system:

  • Yellow patients are those who have complex discharges to home. Yellow patients will be contacted the day after discharge and intermittently throughout the 30 day post-hospital period.
  • Green patients are those who will be transitioned to a different facility. We will be in communication with the receiving facilities 48 hours post -discharge to ensure all communication has been received, is effective, and there are no questions regarding the patient who was transferred.
  • Blue patients are those who are expected to go home with little to no significant discharge needs. These patients will receive a call the day following discharge. Nursing has done a great job getting systems and structures in place for these calls to occur and are sharing new resources to support these Providence Regional Medical Center patients.

We have come far already, but know we still have a lot of work left to do. Our hope is to stabilize the process in the next few weeks as we work to follow agreed upon workflow processes, establish new communication paths, and stabilize staffing. We consistently look for more opportunities to better support patient transition including the use of technology through the discharge process. New transition processes will begin at Pacific Campus and the Pavilion in the next 30 days leveraging our learnings from Colby. 

As we work through rebuilding internal processes, we are hearing wonderful feedback from patients with strong appreciation for the post-discharge phone calls.  We have been able to avoid readmissions a number of times just by a simple phone call! We found a patient who did not get his prescription filled because it required pre-authorization, we intervened when home health had not been able to assist our patient post-discharge, we arranged for home health when we found a patient had insulin but no syringes, and we have had a number of patients who were missing equipment after we arranged for it to be delivered. Great catches by transition coordinators, transition planning RNs, care coordinators at The Everett Clinic and Providence Medical Group,  as well as the float resource team all doing patient phone calls!

We have done an initial review of data regarding length of stay and average time of discharge and have found that on a day-to-day basis, there is fluctuation. Monthly data from the past year shows the month of August is in the range of previous months.  The same can be said for our average discharge time. Many of you are aware of patients waiting to discharge and I thank you for your feedback and concerns as we evolve this new set of processes.

We began sharing the need to transform care and to lower the overall cost of care for Snohomish County more than a year ago.  This work is essential in order to ensure our ability to provide excellent, high quality healthcare. We will all need to make substantial changes in how we do our work to see this goal become reality. It is not enough for us to think it will get “fixed” without our active engagement, and without each of us thinking differently about how we do our work. I appreciate how hard this is, and also know we have just gotten started on our journey. 

Thanks to each of you for your commitment to our patients and our community.