The Health Transition Program has gained statewide recognition from the Wisconsin Hospital Association (WHA) for being a best practice in the state and for being a leader in dramatically decreasing hospital readmission rates over the past several months.

“We do so much to educate the patient before we send them home from the hospital. But that’s not always enough,” says Health Transitions Clinical Resource Leader Linda Holzheuter, RN, BSN. “The follow-up after they return home provides the extra care, tailored education and a safety net that helps to facilitate a successful recovery.”

Since September 2012, the hospital’s re-admission rate has continuously been below the statewide re-admission rate of 13.0 per 100 patients and is now below the target rate of 5.0 re-admissions per 100 patients.

Caroline Arndt of Watertown was hospitalized earlier this year with congestive heart failure. Released after her overnight stay, 85-year-old Caroline returned home with multiple medications and dosages, a new oxygen tank, a long list of symptoms to watch out for, and advice on changing her lifestyle.

It was overwhelming to say the least. Health Transitions nurse Kathy Henze, RN entered the picture.

“I met with Caroline the day after she returned home,” says Kathy. “At our first visit, I checked her oxygen level, made sure the tank was working, and talked about a low salt diet.”

“Kathy told me things I did not even realize,” says Caroline. “I learned a lot from her. I love Ramen noodles, but they’ve got so much sodium in them! I never knew!”

Health Transitions nurses act as personal health coaches. They visit the patient during their hospital stay and schedule a home visit within days of the patient returning home. Nurses review the plan of care, using a patient-centered approach to teaching. Follow-up phone calls continue weekly for 30 days post-discharge and additional home visits are conducted as necessary.

Jacklynn Lesniak, RN, BSN, MS and WRMC’s Chief Nursing Officer says, “This work is just the beginning of how WRMC is working to transform health, one life at a time. The reduction in our re-admission rate is proof that our innovations are changing lives for the better.”

Having coordinated with Caroline’s physician, Kathy also knew that Caroline - - a spry and energetic woman - - had a history of waiting until her symptoms were so bad that emergency care was required. So Kathy spent time reviewing early signs and symptoms of a flare-up with Caroline and emphasized the advantages of seeing her doctor at the first sign of trouble.
 
“I knew nothing about congestive heart failure,” Caroline continues. “I didn’t realize how close to leaving this earth I had been. Where else would I have found all this information?”

Holzhueter will showcase work of the Health Transitions team as a guest speaker at a Wisconsin Hospital Association Partners for Patients event in March.