WY Rural Care Transition Program available to community through Memorial Hospital

WY Rural Care Transition Program available to community through Memorial Hospital

Greer Ferrero RN, Care Transition Nurse, helps Tari Lewis understand the reasons for taking her medications. Tari explains, "Greer also attended my doctor appointments with me and helped explain to the doctor what was going on at home. What a great new hospital program, I feel lucky to be involved with the Care Transition Program."

ROCK SPRINGS — Memorial Hospital of Sweetwater County would like to introduce a new program that has been implemented for Sweetwater County residents through their facility.

The Wyoming Rural Care Transition Program is a statewide patient-centered program designed to improve quality, reduce re-hospitalization and contain costs for patients who are 65 years of age and older with at least one of the 10 qualifying diagnoses.

The Wyoming Institute of Population Health (Institute) was given a $14.2 million CMS Health Care Innovation Award (HCIA) to support hospitals and physicians across Wyoming transform care in their communities. The Health Care Innovation Award was supported by the CMS (Centers for Medicare and Medicaid Services) Center for Medicare and Medicaid Innovation. Wyoming is the only state that has been awarded this grant.

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This program provides Care Transition Nurse Coaches to help guide patients as they transition across multiple health care settings. The program focuses on providing patients and their family/caregiver with information necessary to manage their own care, improve their quality of life, and know where to go for assistance within the health care system.

Some of the benefits of the program are an increased ability of the patient to self-manage care and health, improve quality of life for patients, and improve patient follow through with physician recommendations and orders after discharge.

Ultimately the program will improve patient care and patient health status, improve quality and safety, reduce re-hospitalization rate and reduce hospital costs.

The Care Transition Program was placed under the Direction of Janelle Nickell, Director of Health Information Management and Case Management. Greer Ferrero, BSN, RN, is the care transition nurse who is making a difference with the patients who choose to sign up for the program. Since the program began in mid-October 2013, 35 patients have signed up to participate in this program.

The care transition nurse will see the patient in the hospital after admission and each day the patient remains hospitalized. The nurse will then go to the patients home and advocate and encourage patient and/or caregiver to take a lead in their diagnoses, medication use and the importance of keeping their appointments with their primary care provider.

The role of the care transition nurse does not replace Home Health nursing services; instead, these two agencies work as a team to maximize services provided to the patient to improve the health of the patient. The care transition nurse will generally visit with a patient (in the hospital, at their home, and on the telephone) approximately 10 times within 90 days, sometimes more, sometimes less. The service is free to the patient. The qualifying patients have had an overwhelmingly positive response for the Care Transition nurse and are very grateful for the resource.