Care coordinators and transition consultants collaborate to reduce readmissions

Transition consultants from the Agency on Aging work closely with the hospital's nurse care coordinators to ensure that patients have a successful discharge from YNHH. Transition consultants in the first row are (l-r): Sarah Vernale, Kimberly Leake and Vickie Ogden. Care coordinators in the second row are (l-r): Ruth Clark, RN; Lynn Triebel, RN; Carolyn Gonzales, RN; and Carolyn Gillespie, RN.  Transition consultant Katie Nants  was unavailable for the photo.
Transition consultants from the Agency on Aging work closely with the hospital's nurse care coordinators to ensure that patients have a successful discharge from YNHH. Transition consultants in the first row are (l-r): Sarah Vernale, Kimberly Leake and Vickie Ogden. Care coordinators in the second row are (l-r): Ruth Clark, RN; Lynn Triebel, RN; Carolyn Gonzales, RN; and Carolyn Gillespie, RN. Transition consultant Katie Nants was unavailable for the photo.

The goal of the Greater New Haven Coalition for Safe Transitions and Readmission Reductions (GNH CoSTARR) is to reduce readmissions of Medicare patients at high risk for hospital readmission. Funded by Medicare, programs around the country like CoSTARR work locally to develop relationships with community agencies that will keep patients safe and healthy so they will not have to be readmitted. The service is provided free to the patient.

At Yale-New Haven, nurse care coordinators work with transition consultants, who are trained social work professionals from the Agency on Aging of South Central Connecticut. Each month, the program targets 300-350 Medicare patients who meet the CoSTARR criteria: patients who have a history of readmissions, take more than three medications, have one of four illnesses and live within a certain distance of the hospital.

"We target these particular patients because they need enhanced support to ensure a successful transition," explains Grace Jenq, MD, medical director, Inpatient Medicine and the CoSTARR Program. "They need help with their meds, they need to be reminded to make an appointment with their primary care physician — or to find a primary care physician — and they may need help getting transportation to that appointment. These are all important elements of a successful post-discharge transition."

Transition consultants meet with the patient prior to discharge and, for the next month, will help whether the patient is at home, in a nursing home or a rehabilitation center. If necessary, the transition consultant will even make a home visit to ensure that the patient is doing well.

"The transition consultants are an important part of our efforts to make sure that the patient has a safe and successful discharge from the hospital," says Dr. Jenq. She notes that the patient's first 72 hours to seven days after discharge determine how successful the patient will be. If the patient's first week is a success, it is likely that they will not need to be readmitted.

In its first year of the CoSTARR trial, YNHH sees improvement in readmission rates on both campuses. Readmissions are down 5 percent among CoSTARR patients and the goal is to decrease readmissions to 20 percent for all patients.

"Being discharged is a complex process and can feel very much like a maze to patients who do not have support at home," said Dr. Jenq. "The care plan helps you navigate the maze perfectly but if you don't execute the care plan just right, you may have to come back here. Our work — hopefully — will help patients avoid that."