Hospitals in pursuit of excellence

Transition to Patient Self-Management

Effective care transitions programs can do more than improve patient care: patients learn to manage their own health and can avoid a hospital readmission. Thomasville (NC) Medical Center, a 146-bed hospital, implemented its TMC to Home program in July 2011 to target at-risk patients with acute MI, CHF, pneumonia, COPD and diabetes. Curtis Reeves, R.N., outpatient case manager, schedules in-hospital visits with patients and daily care conferences at 10 a.m. and 3 p.m. with caregivers from all disciplines to lay the groundwork for discharge needs. Depending on the severity of their condition, patients receive follow-up care by phone or home visits. Reeves completes medication reconciliation, provides education, may discuss end-of-life issues and connects many patients to existing community resources. From August 2011 to October 2012, 30-day readmissions for all targeted conditions have decreased, including a 66 percent decrease for AMI patients, 44.7 percent decrease for CHF patients and 43.6 percent decrease for COPD patients. Reeves also estimates that, in the program’s first 14 months, 13 30-day readmissions were averted. Reeves notes, “At Novant Health, we are reinventing health care, and helping patients get the tools and resources they need to take ownership of their health, which is the cornerstone of this program. We achieve this through patient engagement and establishing personal relationships.”

For more information, contact Reeves at cwreeves@novanthealth.org.