- Website URLhttp://www.wakehealth.edu
- Phone Number336-716-2011
How We Improve Care Transitions
- Transitional Care and supportive (hospice/palliative) services
- Bridging to home
- Ambulatory Care Navigator (in select MD offices) to follow chronic disease.
- Working with 5 nursing homes; MD follows monthly meetings to improve care and communication with care givers. lan to add NP/PA to see patients in house follow in the 5 SNFs we cover, and ensure transitions to home with needed resources.
- Nurses in ED
- Readmission Coordinator
- Hospice/Palliative Care Referrals and Education
The Care Transitions Program has successfully planned and began implementation of five programs focused on improving care transitions and reducing Wake Forest Baptist Medical Center’s all-cause readmission rate. We are in partnership with six local nursing facilities to develop skilled nursing Transitional Care Units (TCUs) within these facilities. The TCUs provide a dedicated space within our partner nursing homes where physicians and nurse practitioners manage the medical and social complexities of patients at high risk for hospital readmissions.
The Care Transitions Program team has integrated hospital care, primary care management, and home health management for patients. We have also executed contracts to develop Wake Forest Baptist Health Care at Home, a joint venture with 40% WFBH ownership. The CMS Community-based Care Transitions Program (CCTP) is being administered by Northwest Community Care Network (NCCN), which serves as the community-based organization (CBO) for the CCTP award in WFBMC’s region. As the CBO, NCCN is partnering with other community agencies to serve targeted high-risk Davidson, Forsyth, and Surry county Medicare Fee-for-Service (FFS) beneficiaries discharged from Wake Forest Baptist Medical Center and seven other hospitals. Services provided by CCTP through navigators (i.e., social workers and nurses) primarily offer short-term in-home visits to assist patients with medication reconciliation, primary care follow up, referral to home care, and referral to long-term community resources. The WFBH Care Transitions Program has funding for two Nurse Practitioner positions. The NP works in partnership with the CCTP navigators and reviews inpatient criteria separately to provide in-home navigational services for medically complex patients potentially at risk of readmissions. Nephrology physician champions lead a multi-disciplinary team consisting of Emergency Department Physicians, Pharmacy, Social Workers, Hospital Nurse Case Managers, Nurse Managers from Outpatient Dialysis facilities, Chaplains, Nursing, Performance Improvement, and Transitional Outcomes. The charge of this team was to develop hospital and community strategies, improve internal processes, and collaborate with cross-continuum partners and providers to improve the care delivered to the Renal dialysis patients with a goal of reducing readmissions. This team also participates in the North Carolina/Virginia Readmissions Collaborative, which is a regional project design and learning network sponsored by the NC Quality Center, which is a part of the NC Hospital Association (NCHA). There are also 3 additional readmission teams that have been formed to address the process, medical management, and post discharge needs of populations specific to key hospital services. CarePlus was created by a diverse group of WFBMC stakeholders who were tasked to develop a comprehensive, patient-centered model of primary care that serves approximately 400 frequently admitted patients who are managed by primary care at two WFBH outpatient clinics. This model is designed to provide intensive services (e.g., longer clinic appointments, home visits) by a multi-disciplinary team (i.e., physician, nurse practitioner, licensed clinical social worker, registered nurse, community health worker, patient service representative) to improve medical, mental health, and functional outcomes for Forsyth County patients. Emergency room navigators will be hired soon who will support transitional management of non-urgent patients back to CarePlus or other PCPs for immediate physician or home visits, back to our transitional care units (TCUs) in nursing homes, to home health, and to palliative and hospice care. We have also re-engineered the way palliative and hospice care is provided to patients within the inpatient setting and to residents within the community. This model provides an integrated approach to provide care more upstream in the disease process and also to provide care based upon placing the patient and family’s needs at the center of decision-making, which allows for the best care at the right place at the right time by the right team. WFBH is also a participant in the Northwest Triad Coalition for Improved Care Coordination, which is a regional coalition formed to improve the coordination of care for patients and residents as they transition across the continuum of services provided by various health care and community-based services. Current and potential members are from Davie, Davidson, Forsyth, Stokes, Surry, Wilkes, and Yadkin counties who represent healthcare systems, home health care agencies, skilled nursing facilities, public health departments, community-based service organizations, philanthropic and faith-based organizations, local businesses, educational institutions, health care providers, patients, and their caregivers.
Bridging the gap between Inpatient and outpatient care.
Currently there are two pharmacists on the transitional and supportive care team at Wake Forest Baptist Hospital. One pharmacist focuses on being a reference and life line to the front line players (NP, PA, CNA) who perform home visits. If the front line players feel the patient would benefit from a pharmacist coming to see them in the home, I will go and do extensive medication therapy management. Also, the other pharmacist is over our PACT (pharmacy assurance of care transitions) team consisting of 20 technicians. This team covers five pillars of service to ensure a safe transition of care for each patient. The techs obtain accurate home med lists, offer our discharge pharmacy service(DPS), and help with medication access issues. The pharmacists counseling our DPS enrolled patients.
DCORI – funded COMPASS study to launch in April 2016. This is a large pragmatic trial (N=50 hospitals in NC) to test a model of comprehensive post acute care services (early supported discharge and transitional care management and community support services) on functional outcomes at 90 days post discharge.
- American Heart Association
- Area Agency on Aging
- Brian Centers in Winston-Salem, Lexington, Winston-Salem NSG/Rehab and Silas Creek Rehab center
- Civic/Faith Organizations
- Community Resource Connections
- Community resources, specialty physicians, Hospice etc.
- Community Service Organizations
- Faith Health Shepaids Center Grace Clinic
- Faith Health/Care Net
- Home Health Agencies
- Hospice/Palliative Care Agencies
- Jostus Warren Taskforce
- Other Long Term Care Communities
- Parish NSG Triad Clinic Care at Home NW Comm Care Senior Services Oak Forest
- Primary Care Offices
- Skilled Nursing Facilities
- Stakeholder partners include patients, clinicians, policy makers, payers, industry
How We Measure Our Efforts
- Data Collection Reports of weekly successes
- The volume or number of people reached, regional readmission rates through CMS, hospital and service line readmissions rates, readmission drivers, readmission rates from cross continuum partners, patient satisfaction, mortality, and others.
- Obtain metrics monthly on how many patients we touch.
increased patient centered outcomes increased function reduced family caregiver stress will also look at health system centered metrics: mortality, readmission, use of TCM billing codes
- AddressMedical Center Blvd, Winston-Salem, NC 27157
- Primary Contact NameCarolyn Bowen, RN, BSN
- Primary Contact Emailcmbowen@wakehealth.edu
- Primary Contact Phone336-713-5274