She didn’t have enough food, and she struggled to keep all of her household chores in check. She took so many medications — for diabetes, for chronic obstructive pulmonary disease, for the pain from her recent surgery — that at times it was nearly impossible to manage them all.
That’s when a care transitions nurse from Christian Health Care Center stepped in. Because this woman had been at CHCC for rehab care after a hospital stay, the care transitions nurse spent a month following up on her — as the nurses do with all rehab patients — to ensure that the client had everything she needed to recuperate at home.
The nurse called a church in the area to see if this client could get any assistance with housekeeping and food. She got help rearranging her appliances so the long tube connecting her to her oxygen tank could reach across the house without trouble. The nurse also helped her make sense of her medications and ensured that she was able to communicate with her doctor during regular checkups.
In the end, CHCC’s care transitions program helped her recover safely at home, keeping her from having to go back to the hospital.
Hundreds of times over, day in and day out, this is what CHCC’s care transitions nurses do. Since the program began in 2012, they’ve seen 727 patients, helping them recover from a variety of conditions and giving them the skills and information they need. Often, they also connect patients with local organizations who may be able to provide other much-needed resources, such as food, housecleaning or at-home care.
“All of us are retired nurses with different areas of expertise, and we love working with people,” says LeAna Osterman, the coordinator of the center’s care transitions program. “We enjoy doing what we can to solve problems and to make life better for our clients.”
Overall, the rate of hospital readmission for Christian Health Care Center’s care transitions program participants is astoundingly low. Less than 4 percent — 3.76 percent, to be exact — of care transitions patients in 2018 were readmitted to the hospital. Across the nation, the average rate of readmission is above 15 percent within 30 days, and even higher at the 45-day mark. On average, CHCC stays with people for 48 days in all (18 days of rehab at the center and an additional 30 days of follow-up from care transitions nurses).
“For CHCC to have kept readmission rates to under 4 percent on an ongoing basis is incredible,” Osterman says. “We know we have saved Medicare a bundle of money on readmissions.”
“Our clients do well; they can live on their own and they don’t end up having to go back to the hospital. This model really makes sense, and we’d like to see it replicated elsewhere.”
LeAna Osterman, CHCC care transitions program coordinator
A bundle indeed. The most conservative estimates are that Medicare pays around $10,000 per day for every patient in the hospital. Multiply that by the 11 percent or so of the program’s 727 patients who otherwise would have been readmitted to the hospital, and it’s likely that CHCC’s care transitions program has saved the government millions — even tens of millions — in hospital costs.
Care transitions clients come to CHCC after hospital stays, usually for knee or hip surgery or for other problems, such as diabetic complications or heart issues. The service is free for clients, provided by Christian Health Care Center. For a month — and sometimes longer, for individuals with additional needs — the care transitions program helps clients understand their medications, ensures they can talk to their doctors, assists them in keeping their medical and therapy appointments, and helps make sure their homes are ready for their recuperation. On occasion, the program works to find new homes for patients, such as at assisted-living centers, or connects them with at-home care to ensure that their needs are being met.
“Our clients do well; they can live on their own and they don’t end up having to go back to the hospital,” Osterman says. “This model really makes sense, and we’d like to see it replicated elsewhere.”