A Smooth Transition

Established in the fall of 2009, Mary Greeley Medical Center's Transitional Care Program ensures that patients' health will continue to be monitored and cared for as they transition from the hospital to their home.

Leo Kinyon and his wife Norah have been living in their house, located along the outskirts of Ames, since 1952. The Kinyons have a cozy home, plenty of farmland and a large guard dog, Simba. Although the 86-year-old suffers from diabetes, chronic obstructive pulmonary disease (COPD), cancer and congestive heart failure, Leo isn’t ready to leave his home for long-term nursing care just yet.

"In August 2008, I had a heart attack, then I had another one last April," Leo says. "I was in the ICCU at Mary Greeley Medical Center for 14 days. The nurses there were wonderful and the food was great, but I was glad to come back home to my wife."Leo and Norah Kinyon

Leo’s care didn’t end when he was discharged from the medical center. With the help of Mary Greeley Medical Center’s Transitional Care Program, Leo was able to monitor and track his health progress from his own living room.

The Transitional Care Program, supported by Quality Management, Cardiopulminary Services and HOMEWARD, aims to reduce the number of patients’ rehospitalizations by monitoring their statuses remotely after they are discharged. The program was initiated in November 2009, and has helped reduce the number of patients who are readmitted to the hospital within 30 days of discharge.

"The program really promotes self-care for patients," says Les White, R.N., B.S.N, M.P.A., HOMEWARD Systems Coordinator. "It’s an extension of the care they received while recovering in the hospital. It’s an excellent opportunity for patients to take advantage of because they receive professional oversight, free of charge, for 30 days."

When a patient is about to be discharged, an attending physician writes an order for the Transitional Care Program. Once the patient is discharged, a HOMEWARD nurse goes to the home and installs a Health Buddy®, a device that relays health information from the patient’s home to the medical center, where nurses and physicians review results. After installing the Health Buddy®, the nurse performs medication
reconciliation with the patient, who will self-manage medications. "The nurse came in and set up the Health Buddy® in less than an hour," Leo says. "It plugs into the wall and uses a telephone line to send my results directly to the hospital. She showed me how to use the machine and what steps to go through each day. It was very easy."

For the first 30 days after his discharge, Leo would wake up each morning and weigh himself on the Health Buddy® scale before getting dressed. After dressing, he would take his blood pressure and pulse, and then send his information to HOMEWARD of the medical center.

"This machine was so simple for me to use," Leo says. "I can just hit a few buttons, weigh myself and take my blood pressure, and that’s about it. It’s so easy, and the great thing is it doesn’t take too much of my energy to use it."

Along with collecting blood pressure, pulse and weight, the Health Buddy® asks a series of questions about symptoms and general health education.

"The Health Buddy® also monitors how patients are feeling by asking symptom-related questions," Angela Doran, R.N., HOMEWARD clinical services manager, says. "Each day there’s also a teaching segment to ensure compliance in managing a patient’s disease. There are simple educational questions like 'which food is higher in salt?'"

Patients are expected to complete their session each day prior to 11 a.m. If the results are missing, or if they are received but do not appear to be within normal limits, a health professional calls the patient and contacts other health care providers involved in the patient’s care.

A nurse performs patient monitoring Monday through Friday, excluding holidays. A patient trend report is sent to the physician on a weekly basis or as needed, depending on the patient's condition and reported results.

"I didn't hear from them during my 30 days because my results were always within normal range," Leo says. "But it was nice to know somebody was looking at my results to check on my health each day."

The Transitional Care Program is currently offered to patients who have been diagnosed with congestive heart failure, pneumonia or COPD and have been discharged from Mary Greeley Medical Center.

"We've seen great success with the Transitional Care Program so far," White says. "As the field continues to grow and we see a greater need for it among patients with other conditions, we expect to expand the
program for other diagnoses."