Category: Social and Community Context

28 - ACTIVATE Transitional Care Program reduces hospital readmission rates using nurse navigators who address both physical and social needs of the patients in their home.

  


Background: ACTIVATE is a partnership with Dignity hospitals Arizona, Foundation for Senior Living (FSL) and Mercy Care Plan that began in 2012. The ACTIVATE transitional care program is a structured patient-centered care process to support a patient’s journey from hospital to home. Focus is on patients with multiple co-morbidities and high re-hospitalization rates. The program draws on best practices from both the Coleman Model and Project RED using an embedded transitional care nurse to work with the in-hospital medical staff to coordinate post discharge care. A home visit is conducted after discharge with routine follow up visits and telephonic touches during the transition period.


Objective: Measured 30-90 day readmission rates for patient population as compared to overall hospital re-admission rates.



Methods:


The program serves the Medicaid, the under insured and uninsured populations. Patients who are high risk of readmission are selected. The two key program elements include the in-hospital engagement period and the home visit. During the in-hospital visit, the patient and nurse navigator build a relationship and preparing for discharge. This includes delivering DME (Durable Medical Equipment, not covered by Insurance), assessing and securing funds for medications, arranging PCP appointments and transportation, and securing resources for other social determinants needs.


During home visit, patient receives a personal health binder which has information related to the patient’s care (Appointments, discharge information, disease specific education, community resources). A nurse navigator spends 2 hours in a patient’s home reviewing medications, appointments and pertinent education. This encourages the patient/caregiver to become more involved in their care and a better self-advocate. True medication reconciliation is done at the kitchen table. A home safety evaluation is completed to help the patient overcome in-home barriers or prevent potential safety hazards.  The nurse navigator is with the patient during the transition making weekly calls to follow up on gaps in care. The program places great emphasis on both the medical needs and the social determents and we see less non-compliance as a result.



Results:


ACTIVATE (Medicaid): 46 readmissions occurred from the 359 completed enrollments = 13% readmission rate. ACTIVATE Prime (Medicare and Uninsured): 107 readmissions from the 963 enrollments = 11% readmission rate.


 


 

Kira McClinton

Program Director
FSL
Phoenix, Arizona

While Kira McClinton has only practiced nursing for a few years, her accomplishments are that of a lifetime. Her faith and servant leadership brought her to the Foundation for Senior Living where she worked as a transitional care nurse and is now the Director of our ACTIVATE transitional care program. Helping the most vulnerable in our community transition safely home is her calling. She is not your traditional nurse. Kira wears many hats each day and finds herself maneuvering a complex web of medical and social services, family dynamics, challenging eligibility requirements, wait lists and other social determinants that stop the majority of people in their tracks. Not Kira. She doesn’t take no for an answer and loves a challenge. The program which started out of one hospital system has grown to serve five hospitals across the valley. Since 2014, under Kira’s leadership the transitional care team assisted 980 high risk hospital patients with their transition home. These individuals have multiple chronic conditions, one or more social determinants impacting their ability to care for their health needs, are on multiple medications, have behavioral health needs and have a history of many hospital admissions and readmissions in a short period of time. Of the 980 enrolled, only 115 had a reoccurrence/re-hospitalization or 14% readmission rate. This high risk population often sees readmissions in the 20-25% range. Engagement starts at the bedside and is integral through every step of the discharge process. Kira and her team have become a part of the process and work hand in hand to ensure patients are ready to go home. A home visit to reconcile medications, conduct teach back exercises specific to the persons disease process and a warm hand off to community organizations is all in a day’s work.

Carrie Smith

Chief Operating Officer
FSL
Phoenix, Arizona

As FSL’s Chief Operating Officer, she is responsible for the organizations core home and community based services programs; with 300+ employees and an annual budget of approximately $20M, these programs serve thousands of clients and their caregivers annually. She ensures regulatory and financial obligations are met, and is responsible for developing the programs’ strategic initiatives. For more than 24 years she has continually looked for and implemented cost-effective ways to meet the needs of Arizona seniors, vulnerable adults and their caregivers so they may continue to live as independent and safe as possible. She does this by working with community stakeholders to create innovative community based care solutions that improve the quality of life for thousands. Her commitment to the community includes serving on various boards and committees such as Energy OutWest, the Arizona Community Action Association, St. Joseph’s Hospital Community Health Integration, the East Valley Dignity Institutional Review Board and many others. She holds a Bachelor’s Degree in Social Work and a Master of Business Administration. Carrie’s passion is to serve; making a difference in the lives of others is what drives her each day.