Reducing Patient Readmissions by Integrating The Reducing Patient Readmissions by Integrating The Reducing Patient Readmissions by Integrating The Expertise of the Expertise of the Expertise of the Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care Viktoriya Fridman, ANP-BC, RN • Barbara Sommer, RN, MA, CEN, NE-BC • Barbara Donovan, RN • Aphene Fraser, RN, MSA • Luis Medina , RN-BC • Danielle Walker, RN Marcia Nelson, DO, R.Ph, RN • Gregory Todd, MD • Thomas Smith, DNP, RN, NEA-BC • Edward H. Wu, R.Ph., CPHQ Maimonides Medical Center, Brooklyn NY Maimonides Medical Center, Brooklyn NY Maimonides Medical Center, Brooklyn NY Identification of Need Identification of Need Identification of Need Older paents experience more complicaons during hospitalizaon and on transion from the hospital to home. During transions, older paents with mulple chronic condions and complex therapeuc regiments are at risk for medical errors and frag- mentaon of care. Many paents encounter a variety of problems in the first weeks post discharge and are therefore readmied to the hospital within 30 days. Avoidance of readmissions depends on the ability and experse of hospital staff to uncover under- lying problems, prevent complicaons and facilitate the transion from hospital to home. Moreover, lack of clear communicaon upon discharge regarding changes in the medicaon regimen, significant signs and symptoms to report and appropriate scheduled follow-up care, adds to the confusion of the paent and caregivers. Current Evidence Current Evidence Current Evidence One-in-five discharged adult medical-surgical paents will be re-hospitalized within 30 days. 50% won't have any interacon with a clinician prior to readmission. Improving communicaon among key members of the care team is essenal to keeping paents safe and informed. Engaged and empowered paents are more likely to understand and follow their discharge instrucons correctly. This will help prevent readmission within 30 days. Researchers have found that numerous issues arise aſter the paent leaves the hospital. For paents at increased risk for readmission, some invesgators recommend both comprehensive discharge planning and a phone call to paents (or caregivers) within 48-96 hours of discharge to assess the paent's clinical status and ability to implement planned treatment and follow-up care. Purpose Purpose Purpose To enhance the ability of the health care team to deliver high quality transional care for hospitalized older adults by blending two models of care: NICHE and BOOST. Goals include: Reduce 30 day readmission rate Increase paent/family sasfacon Reduce length of stay Improve paent/family preparaon for discharge transion Reduce disconnuity and fragmentaon of care Improve staff sasfacon Background Background Background A project funded by the New York Community Trust from 2010 to 2011 was implemented at Maimonides Medical Center in Brooklyn, New York. Both NICHE and BOOST models of care were implemented simultaneously on two pilot medical units (Kronish 7 & Gellman 7 East). Fiſty-five percent of the discharged paents on these two units are over the age of 65. Moreover these two units have strong physician and nurse co-management teams. The nursing culture is also focused on providing excellence in care to older paents. Methods Methods Methods Monthly core-team meengs Daily interdisciplinary discharge rounds Monthly Geriatric Journal Club Nursing Grand Rounds, presented by staff nurses on the pilot units Paent and family educaon via NICHE and Micromedex posters and handouts Hospital intranet communicaon and markeng of the program of care Use of NICHE designaon posters & brochures Implementation Implementation Implementation This project included the implementaon of two programs: Nurses Improving the Care of Healthsystem Elders (NICHE) and BOOST (Beer Outcomes for Older adults through Safe Transions). Appointed an interdisciplinary steering commiee. Launched NICHE-BOOST Training conferences, and online webinars. Implemented the Geriatric Resource Nurse (GRN) Model of Care. Integrated BOOST principals of transional care model in to the Geriatric Resource Nurse educaonal plaorm. Ulized BOOST tools for care transions. Restructured weekly interdisciplinary rounds by empowering nursing staff and im- proving interdisciplinary team relaonship. SPICES assessment tool was integrated in- to the rounds framework and approach. Use of evidence-based pracce protocols. Enhanced nurse-physician collaboraon throughout all phases of acute care. Components Components Components NICHE evidence-based protocols ★ SPICES assessment tool. Designed SPICES wall boards that are ulized during interdisciplinary rounds. ★ “Try This” Best Pracces in Nursing Care to Older Adults series BOOST tool kit to facilitate transions of care: ★ Teach-Back Methodology. Implemented the teach-back process of paent educaon to ensure paents/caregiver's understanding of post hospital care requirements. ★ Follow-Up Paent Calls to assess the paent's condion and adherence to discharge instrucons at home within 72 hours of discharge. The calls were conducted and im- plemented by an advanced pracce nurse using a short quesonnaire. ★ “Paent-Friendly” Discharge Note was developed and implemented on two pilot units. Discharge Note is iniated and completed by staff nurses. Medicaon reconciliaon and care notes are provided to the paents on the date of discharge in one folder. A copy was ulized during follow-up calls to assess paent knowledge. ★ Schedule Follow-up Appointments within 7 days of discharge to assure mely access to key healthcare providers aſter an episode of inpaent care as required by paent’s condion and needs. ★ Fill Prescripon Program. Paents are able to prefill their medicaon prescripons at the hospital-based pharmacy. The clinical pharmacist completes the medicaon reconciliaon list and provides paent/caregiver educaon by ulizing the teach-back methodology. ★ Nursing, medical and non-physician geriatric staff educaon: GRN training for staff nurses. Nursing Grand Rounds presented by Geriatric Resource Nurses and physician champion “The Pathway to Excellence in Care of Older Adults”. Medicine Grand Rounds led by BOOST Principal Invesgator Mark V. Williams, MD New protocols: Delirium, CAM, BOOST tools. Teach-Back Methodology Interdisciplinary Interdisciplinary Interdisciplinary Collaboration Collaboration Collaboration The interdisciplinary health care team working closely with the paent and their family is important in idenfying issues of concern. The core team members are: Nursing: NICHE-BOOST Coordinator, CNO, Senior Nurse Leaders, Nurse Managers, Staff Nurses Hospitalists: Physician Champions Case Management: CM Leadership, Unit-based CM, Clinical SW, SW Assistant PI: Quality Analyst, Data managers Pharmacy: Clinical pharmacist and pharmacy technician Nutrion Rehabilitaon: PT, OT, ST Paent Relaons: Paent Representave Challenges Challenges Challenges Short me frame. The grant was funded in July 2010. Core team members completed both trainings in November 2010 and project went live in February 2011. Delayed Paent-Friendly Discharge Note implementaon due to IS technical glitches. Impact on team dynamics of new residents every month Compeng leadership priories within the Department of Nursing HCAHPS data are hospital based and not unit specific Conclusion Conclusion Conclusion During this pilot project, older adults hospitalized on both pilot units received high quality transional care delivered by expert Geriatric Resource Nurses and core members of an interdisciplinary team. Results demonstrated reducon in length of stay and re-hospitalizaon during a 30-day period. Comprehensive discharge planning, paent educaon through the teach back methodology and post discharge follow-up calls are core components of the transional care model. Integrang NICHE and BOOST care models helps migate the effects of disconnuity and bridges the gap between hospital and home for paents with complex or mulple health problems. In addion, the NICHE-BOOST model has the potenal to profoundly improve both the quality-of – life for paents and the financial well-being of the healthcare system. Follow Follow Follow- Up Calls Analysis Up Calls Analysis Up Calls Analysis Several researchers have found that despite excellent in-hospital discharge planning, numerous issues arise once the paent leaves the hospital. During seven months of project implementaon all 770 paents discharged home were called within 72 hours aſter discharge. All age groups were included in follow-up call program. 54% of all paents were > 65 years of age. 68% of all paents were reached with 2 call aempts. 32% of paents were not reached due primarily to (1) no answer, (2) language barrier. Diverse language and culture groups were followed during this study which challenged the follow-up call program. 21% of all discharged paents were non-English speaking were 6.7% Chinese, 3.6% Spanish and 9.7 % Russian. Inquires explored during the interviews included (1) current health status, (2) ability to fill prescripons, (3) understanding of discharge instrucons, (4) determinaon if there was a scheduled provider follow-up appointment, (5) determinaon if home care services had begun, if required. 25% had a variety of problems within the first 72 hours aſter discharge. Common issues idenfied were: (1) worsening clinical symptoms, (2) no follow-up provider appoint- ment, (3) unfilled medicaon prescripons, (4) need for discharge instrucon reinforce- ment, (5) need for home care services, (6) medicaon quesons/concerns. All issues were addressed in real-me on the phone call with an addional follow-up if necessary. One month follow up call data analysis revealed that 16.4% of paents/caregivers were not able to recall discharge instrucons from discharge form and needed further reinforcement. Did everything to help your pain? Did everything to help your pain? Did everything to help your pain?- score increased by 2.47% (66.7 - 68.3) Nurses explained things understandably Nurses explained things understandably Nurses explained things understandably- score increased by 10.9% (63.3 - 70.2) Nurses listened carefully to you Nurses listened carefully to you Nurses listened carefully to you- score increased by 6.4% (64.6 - 68.7) Treated w/courtesy/respect by Nurses Treated w/courtesy/respect by Nurses Treated w/courtesy/respect by Nurses- score increased by 4.2% (73.1- 76.2) Although this is not unit specific data there is a probability that paent sasfacon was improved on two pilot units. In addion, most of the paents expressed their appreciaon of post-discharge support during follow-up calls. An analysis showed that all hospital units had a decrease in LOS due to a concurrent hospital-wide iniave, but NICHE-BOOST units showed higher reducon than the controls. Unit K7- reduced by 19.35% (6.94 - 5.60 days) Unit 7E- reduced by 11.40% (6.78 - 6.00 days) Unit 6E- reduced by 8.44% (6.55 - 6.00 days) All Medical Units- reduced by 10.65% (6.36 - 5.68 days) Results Results Results Data were compared 7 months pre-intervenon (Jul-10—Jan-11) and 10 months post-intervenon (Feb-11— Nov-11). The results demonstrate improvements in length of stay, 30 day readmission and paent sasfacon. The two pilot medical units K7 & 7E were compared to both one control medical unit and all medical units. Paent sasfacon was analyzed based on hospital specific data. Average Length of Stay Average Length of Stay Average Length of Stay Average 30 Average 30 Average 30-Day Readmission Rate Day Readmission Rate Day Readmission Rate An analysis showed that both pilot units had a significant change compared to both the control unit and all medical units. Even though 7E had a readmission rate spike of 19% in the month of July, the number dropped to 6 in the subsequent two months. This fluctuaon is possibly due to low unit census, high number of discharges and first month of new intern rotaon. Unit K7- reduced by 24.0% (13.1% - 9.9%) Unit 7E- reduced by 16.1% (15.5% - 13.0%) Unit 6E- reduced by 2.7% (12.77% - 12.43%) All Medical Units- reduced by 3.1% (14.1 – 13.7%) Paent Sasfacon in Nursing Care Paent Sasfacon in Nursing Care Paent Sasfacon in Nursing Care An analysis of paent sasfacon with nursing care revealed a slightly posive change in four nursing-sensive quesons. References References References Alper, E., Greenwald, J., O'Malley, T.A. (2012). Hospital discharge. UpToDate. Retrieved from hp://www.uptodate.com/contents/hospital-discharge. Coleman E.A., Misky G.J., Wald H.L. (2010). Post-hospitalizaon transions: Examining the effects of ming of primary care provider follow-up. Journal of Hospital Medicine. 5(7), 392–397. Bixby, M. B., & Naylor, M. D. (2009). The Transional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults. Try This: Best Pracces in Nursing Care to Older Adults. Retrieved from hp://consultgerirn.org/uploads/File/trythis/try_this_26.pdf Burke, M., Boal, J., & Mitchell, R. (2004). Communicang for beer care: improving nurse-physician communicaon. American Journal of Nursing, 104 (12), 40-48. Retrieved from hp://ovidsp.tx.ovid.com/sp-3.3.1a/ovidweb.cgi Capezu, E., & Brush, B. L. (2009). Implemenng Geriatric Care Models: What Are We Waing For? Geriatric Nursing, 30(3), 204-206. Jencks SF, Williams MV, Coleman EA. Rehospitalizaons among paents in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418. McGaw, J., Conner, D. A., Delate, T. M., Chester, E. A., & Barnes, C. A. (2007). A Muldisciplinary Approach to Transion Care: A Paent Safety Innova- on Study. Permanente Journal, 11 (4), 4-9. Retrieved from hp://xnet.kp.org/permanentejournal/Fall07/transion_care.pdf Snow, V., Beck, D., Budnitz, T., Miller, D. C., Poer, J., Wears, R.L.,...Williams, M. V. (2009, August). Transions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. Journal of Hospital Medicine 4 (6). doi: 10.1002/jhm.510 Process Process Process
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Reducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating The Expertise of the Expertise of the Expertise of the Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care
Viktoriya Fridman, ANP-BC, RN • Barbara Sommer, RN, MA, CEN, NE-BC • Barbara Donovan, RN • Aphene Fraser, RN, MSA • Luis Medina , RN-BC • Danielle Walker, RN
Marcia Nelson, DO, R.Ph, RN • Gregory Todd, MD • Thomas Smith, DNP, RN, NEA-BC • Edward H. Wu, R.Ph., CPHQ
Maimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NY
Identification of Need Identification of Need Identification of Need Older patients experience more complications during hospitalization and on transition from the hospital to home. During transitions, older patients with multiple chronic conditions and complex therapeutic regiments are at risk for medical errors and frag-mentation of care. Many patients encounter a variety of problems in the first weeks post discharge and are therefore readmitted to the hospital within 30 days. Avoidance of readmissions depends on the ability and expertise of hospital staff to uncover under-lying problems, prevent complications and facilitate the transition from hospital to home. Moreover, lack of clear communication upon discharge regarding changes in the medication regimen, significant signs and symptoms to report and appropriate scheduled follow-up care, adds to the confusion of the patient and caregivers.
Current EvidenceCurrent EvidenceCurrent Evidence One-in-five discharged adult medical-surgical patients will be re-hospitalized within 30 days. 50% won't have any interaction with a clinician prior to readmission. Improving communication among key members of the care team is essential to keeping patients safe and informed. Engaged and empowered patients are more likely to understand and follow their discharge instructions correctly. This will help prevent readmission within 30 days. Researchers have found that numerous issues arise after the patient leaves the hospital. For patients at increased risk for readmission, some investigators recommend both comprehensive discharge planning and a phone call to patients (or caregivers) within 48-96 hours of discharge to assess the patient's clinical status and ability to implement planned treatment and follow-up care.
PurposePurposePurpose To enhance the ability of the health care team to deliver high quality transitional care for hospitalized older adults by blending two models of care: NICHE and BOOST. Goals include: Reduce 30 day readmission rate
Increase patient/family satisfaction
Reduce length of stay
Improve patient/family preparation for discharge transition
Reduce discontinuity and fragmentation of care
Improve staff satisfaction
BackgroundBackgroundBackground A project funded by the New York Community Trust from 2010 to 2011 was implemented at Maimonides Medical Center in Brooklyn, New York. Both NICHE and BOOST models of care were implemented simultaneously on two pilot medical units (Kronish 7 & Gellman 7 East). Fifty-five percent of the discharged patients on these two units are over the age of 65. Moreover these two units have strong physician and nurse co-management teams. The nursing culture is also focused on providing excellence in care to older patients.
MethodsMethodsMethods Monthly core-team meetings
Daily interdisciplinary discharge rounds
Monthly Geriatric Journal Club
Nursing Grand Rounds, presented by staff nurses on the pilot units
Patient and family education via NICHE and Micromedex posters and handouts
Hospital intranet communication and marketing of the program of care
Use of NICHE designation posters & brochures
ImplementationImplementationImplementation This project included the implementation of two programs: Nurses Improving the Care of Healthsystem Elders (NICHE) and BOOST (Better Outcomes for Older adults through Safe Transitions).
Appointed an interdisciplinary steering committee.
Launched NICHE-BOOST Training conferences, and online webinars.
Implemented the Geriatric Resource Nurse (GRN) Model of Care.
Integrated BOOST principals of transitional care model in to the Geriatric Resource Nurse educational platform.
Utilized BOOST tools for care transitions.
Restructured weekly interdisciplinary rounds by empowering nursing staff and im-proving interdisciplinary team relationship. SPICES assessment tool was integrated in-to the rounds framework and approach.
Use of evidence-based practice protocols.
Enhanced nurse-physician collaboration throughout all phases of acute care.
ComponentsComponentsComponents NICHE evidence-based protocols
★ SPICES assessment tool. Designed SPICES wall boards that are utilized during interdisciplinary rounds.
★ “Try This” Best Practices in Nursing Care to Older Adults series
BOOST tool kit to facilitate transitions of care:
★ Teach-Back Methodology. Implemented the teach-back process of patient education to ensure patients/caregiver's understanding of post hospital care requirements.
★ Follow-Up Patient Calls to assess the patient's condition and adherence to discharge instructions at home within 72 hours of discharge. The calls were conducted and im-plemented by an advanced practice nurse using a short questionnaire.
★ “Patient-Friendly” Discharge Note was developed and implemented on two pilot units. Discharge Note is initiated and completed by staff nurses. Medication reconciliation and care notes are provided to the patients on the date of discharge in one folder. A copy was utilized during follow-up calls to assess patient knowledge.
★ Schedule Follow-up Appointments within 7 days of discharge to assure timely access to key healthcare providers after an episode of inpatient care as required by patient’s condition and needs.
★ Fill Prescription Program. Patients are able to prefill their medication prescriptions at the hospital-based pharmacy. The clinical pharmacist completes the medication reconciliation list and provides patient/caregiver education by utilizing the teach-back methodology.
★ Nursing, medical and non-physician geriatric staff education:
GRN training for staff nurses.
Nursing Grand Rounds presented by Geriatric Resource Nurses and physician champion “The Pathway to Excellence in Care of Older Adults”.
Medicine Grand Rounds led by BOOST Principal Investigator Mark V. Williams, MD
New protocols: Delirium, CAM, BOOST tools.
Teach-Back Methodology
Interdisciplinary Interdisciplinary Interdisciplinary CollaborationCollaborationCollaboration The interdisciplinary health care team working closely with the patient and their family is important in identifying issues of concern. The core team members are: Nursing: NICHE-BOOST Coordinator, CNO, Senior Nurse Leaders, Nurse Managers,
Staff Nurses
Hospitalists: Physician Champions
Case Management: CM Leadership, Unit-based CM, Clinical SW, SW Assistant
PI: Quality Analyst, Data managers
Pharmacy: Clinical pharmacist and pharmacy technician
Nutrition
Rehabilitation: PT, OT, ST
Patient Relations: Patient Representative
ChallengesChallengesChallenges Short time frame. The grant was funded in July 2010. Core team members completed
both trainings in November 2010 and project went live in February 2011.
Delayed Patient-Friendly Discharge Note implementation due to IS technical glitches.
Impact on team dynamics of new residents every month
Competing leadership priorities within the Department of Nursing
HCAHPS data are hospital based and not unit specific
ConclusionConclusionConclusion During this pilot project, older adults hospitalized on both pilot units received high quality transitional care delivered by expert Geriatric Resource Nurses and core members of an interdisciplinary team. Results demonstrated reduction in length of stay and re-hospitalization during a 30-day period. Comprehensive discharge planning, patient education through the teach back methodology and post discharge follow-up calls are core components of the transitional care model. Integrating NICHE and BOOST care models helps mitigate the effects of discontinuity and bridges the gap between hospital and home for patients with complex or multiple health problems. In addition, the NICHE-BOOST model has the potential to profoundly improve both the quality-of –life for patients and the financial well-being of the healthcare system.
FollowFollowFollow---Up Calls AnalysisUp Calls AnalysisUp Calls Analysis Several researchers have found that despite excellent in-hospital discharge planning, numerous issues arise once the patient leaves the hospital. During seven months of project implementation all 770 patients discharged home were called within 72 hours after discharge. All age groups were included in follow-up call program. 54% of all patients were > 65 years of age. 68% of all patients were reached with 2 call attempts. 32% of patients were not reached due primarily to (1) no answer, (2) language barrier.
Diverse language and culture groups were followed during this study which challenged the follow-up call program. 21% of all discharged patients were non-English speaking were 6.7% Chinese, 3.6% Spanish and 9.7 % Russian.
Inquires explored during the interviews included (1) current health status, (2) ability to fill prescriptions, (3) understanding of discharge instructions, (4) determination if there was a scheduled provider follow-up appointment, (5) determination if home care services had begun, if required.
25% had a variety of problems within the first 72 hours after discharge. Common issues identified were: (1) worsening clinical symptoms, (2) no follow-up provider appoint-ment, (3) unfilled medication prescriptions, (4) need for discharge instruction reinforce-ment, (5) need for home care services, (6) medication questions/concerns. All issues were addressed in real-time on the phone call with an additional follow-up if necessary.
One month follow up call data analysis revealed that 16.4% of patients/caregivers were not able to recall discharge instructions from discharge form and needed further reinforcement.
Did everything to help your pain?Did everything to help your pain?Did everything to help your pain?- score increased by 2.47% (66.7 - 68.3)
Nurses explained things understandablyNurses explained things understandablyNurses explained things understandably- score increased by 10.9% (63.3 - 70.2)
Nurses listened carefully to youNurses listened carefully to youNurses listened carefully to you- score increased by 6.4% (64.6 - 68.7)
Treated w/courtesy/respect by NursesTreated w/courtesy/respect by NursesTreated w/courtesy/respect by Nurses- score increased by 4.2% (73.1- 76.2)
Although this is not unit specific data there is a probability that patient satisfaction was improved on two pilot units. In addition, most of the patients expressed their appreciation of post-discharge support during follow-up calls.
An analysis showed that all hospital units had a decrease in LOS due to a concurrent hospital-wide initiative, but NICHE-BOOST units showed higher reduction than the controls.
Unit K7- reduced by 19.35% (6.94 - 5.60 days)
Unit 7E- reduced by 11.40% (6.78 - 6.00 days)
Unit 6E- reduced by 8.44% (6.55 - 6.00 days)
All Medical Units- reduced by 10.65% (6.36 - 5.68 days)
ResultsResultsResults Data were compared 7 months pre-intervention (Jul-10—Jan-11) and 10 months post-intervention (Feb-11— Nov-11). The results demonstrate improvements in length of stay, 30 day readmission and patient satisfaction. The two pilot medical units K7 & 7E were compared to both one control medical unit and all medical units. Patient satisfaction was analyzed based on hospital specific data.
Average Length of StayAverage Length of StayAverage Length of Stay
Average 30Average 30Average 30---Day Readmission RateDay Readmission RateDay Readmission Rate
An analysis showed that both pilot units had a significant change compared to both the control unit and all medical units. Even though 7E had a readmission rate spike of 19% in the month of July, the number dropped to 6 in the subsequent two months. This fluctuation is possibly due to low unit census, high number of discharges and first month of new intern rotation.
Unit K7- reduced by 24.0% (13.1% - 9.9%)
Unit 7E- reduced by 16.1% (15.5% - 13.0%)
Unit 6E- reduced by 2.7% (12.77% - 12.43%)
All Medical Units- reduced by 3.1% (14.1 – 13.7%)
Patient Satisfaction in Nursing CarePatient Satisfaction in Nursing CarePatient Satisfaction in Nursing Care An analysis of patient satisfaction with nursing care revealed a slightly positive change in four nursing-sensitive questions.
ReferencesReferencesReferences Alper, E., Greenwald, J., O'Malley, T.A. (2012). Hospital discharge. UpToDate. Retrieved from http://www.uptodate.com/contents/hospital-discharge. Coleman E.A., Misky G.J., Wald H.L. (2010). Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. Journal
of Hospital Medicine. 5(7), 392–397.
Bixby, M. B., & Naylor, M. D. (2009). The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults. Try This: Best Practices in Nursing Care to Older Adults. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_26.pdf
Burke, M., Boal, J., & Mitchell, R. (2004). Communicating for better care: improving nurse-physician communication. American Journal of Nursing, 104 (12), 40-48. Retrieved from http://ovidsp.tx.ovid.com/sp-3.3.1a/ovidweb.cgi
Capezuti, E., & Brush, B. L. (2009). Implementing Geriatric Care Models: What Are We Waiting For? Geriatric Nursing, 30(3), 204-206.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418.
McGaw, J., Conner, D. A., Delate, T. M., Chester, E. A., & Barnes, C. A. (2007). A Multidisciplinary Approach to Transition Care: A Patient Safety Innova-tion Study. Permanente Journal, 11 (4), 4-9. Retrieved from http://xnet.kp.org/permanentejournal/Fall07/transition_care.pdf
Snow, V., Beck, D., Budnitz, T., Miller, D. C., Potter, J., Wears, R.L.,...Williams, M. V. (2009, August). Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. Journal of Hospital Medicine 4 (6). doi: 10.1002/jhm.510
ProcessProcessProcess
Reducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating The Expertise of the Expertise of the Expertise of the Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care
Viktoriya Fridman, ANP-BC, RN • Barbara Sommer, RN, MA, CEN, NE-BC • Barbara Donovan, RN • Aphene Fraser, RN, MSA • Luis Medina , RN-BC • Danielle Walker, RN
Marcia Nelson, DO, R.Ph, RN • Gregory Todd, MD • Thomas Smith, DNP, RN, NEA-BC • Edward H. Wu, R.Ph., CPHQ
Maimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NY
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