Reducing Hospital Readmissions

Care transitions program nurses ensure patient get proper follow-up care

With the goal of providing the right care in the right place at the right time, Sutter Health’s Alta Bates Summit Medical Center and the Community Health Center Network in Oakland, Calif., are working together to offer greater access to primary medical care for patients who often rely on the emergency department (ED) for their primary care. Our care transitions program places registered nurses at three Oakland and Berkeley community clinics. In this way, we work to ensure that patients establish a convenient medical home where they can make a follow-up appointment and get routine care.

Be-Verlyn T. Navarro, RN, BS, CEN, is the nurse manager of the emergency department Don Gerda/thanks to Cleveland Clinic
Be-Verlyn T. Navarro, RN, BS, CEN, is the nurse manager of the emergency department Don Gerda/thanks to Cleveland Clinic

Care transitions nurses work with approximately 3,600 patients a year who visit the ED or are admitted to Alta Bates Summit, receive care and are discharged. My colleague John Mullen, RN, an ED charge nurse, says, “This is the best program that’s been implemented at Alta Bates Summit in the 8 years I’ve worked here.”

Like most hospitals and emergency departments, Alta Bates Summit is open 24 hours a day with top-notch staff to care for everyone who walks through our doors. Most days, that includes a lot of people who come to our ED for nonemergencies.

Members of our community who are underinsured or uninsured, homeless or living in poverty, and those with behavioral health problems, frequently use the emergency room for primary healthcare. These patients account for almost half of those making visits to the ED for symptoms that are not life- threatening.

Data Supports New Approach

In 2014, the Community Health Center Network tracked the outcomes of 600 of the program’s 3,600 patients and found that patients in the care transitions program experienced the following:

A 32% increase in primary care follow-up within 30 days of first admission to the hospital; a 17% decrease in ED visits within 30 days of first admission to the hospital; and a 17% decrease in hospital readmission within 30 days of discharge. For a relatively young program, these findings are remarkable.

Partnering with Health Centers

To ensure a smooth transition and continuing care in the community, Alta Bates Summit relies on relationships with Asian Health Services, LifeLong Medical Care and La Clinica de La Raza.

Working collaboratively with our inpatient case managers, the RNs at the health centers let our physicians know, in real time, about patient needs. The goal is to facilitate optimal primary care, health and wellness.

Positive Effects in the ED

In the ED, care transitions case managers collaborate with medical staff. Once the patient is discharged, the case managers help arrange transportation, determine eligibility for home health benefits and outpatient treatments, and explain financial assistance programs and community resources. Most importantly, case managers help patients make necessary follow-up appointments.

Expanding Community Care

In 2015, Alta Bates Summit partnered with La Clinica to place a care transitions nurse at Sutter Delta Medical Center in Antioch. This initiative is being replicated with Tuburcio Vasquez Health Center at Eden Medical Center in Castro Valley. Approximately 500 of our East Bay hospital patients are contacted each month, and 80% of them are keeping their appointments. The care transitions program shows how our partnerships are improving care for the most vulnerable.