The Transitions of Care Center team includes, from left: Amanda Anderson, MSN, MPA, RN; Claudia Colgan; and Eunice Reynoso, BSN, RN, Clinical Nurse Manager.

When a patient is admitted to a hospital within the Mount Sinai Health System, planning for discharge begins almost immediately to ensure a smooth transition to the next level of care, whether it is at home or at a skilled nursing facility. Studies show that effective discharges lead to improved patient health, reduced readmissions, and decreased health care costs.

Toward that end, the Mount Sinai Health System has established the Transitions of Care Center (TOCC), a centralized telephone-based discharge program staffed by Mount Sinai registered nurses who are specially trained in hospital discharge protocols and are led by a clinical nurse manager.

The TOCC has been tasked with improving patient satisfaction, ensuring patients have access to post-hospital care and are following discharge instructions, and preventing avoidable readmissions. Staff work from a dedicated office on East 16th Street near Union Square in Manhattan, where 11 registered nurses call Mount Sinai patients 24 to 72 hours after they leave the hospital—reviewing and addressing each patient’s unique discharge plan of care.

The Center initially was launched in December 2016 as a pilot program aimed exclusively at patients deemed at high risk for rehospitalization. The program quickly expanded and is now servicing patients regardless of readmission risk or diagnosis who are discharged home from The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West, and Mount Sinai St. Luke’s. In March, the TOCC will add discharged patients from Mount Sinai Brooklyn, with a goal to expand to Mount Sinai Beth Israel in the coming months.

Since the program’s start, nurses have made more than 40,000 phone calls, spoken to nearly 19,000 patients, and provided close to 11,000 interventions to assist patients with post-discharge care needs. “The results have been positive,” says Claudia Colgan, Vice President, Care Coordination, Mount Sinai Health System, and Vice President, Operations, The Mount Sinai Hospital. “In the 12 months leading up to August 2018, patients who were contacted by the TOCC had a 16 percent lower-than-expected readmission rate.”

The Transitions of Care Center nursing staff includes Verisa Robinson BSN, RN, center, and from left: Alla Aminova, BSN, RN; Maki Lahori, BSN, RN; Kristina Davanzo, BSN, RN; Amanda Mendez- Paranavitana, BSN, RN; Connie Fong, BSN, RN; and April Schott-Auerbach MSN, RN, CNL.

While speaking to patients, nurses assess their health status and determine if they are adhering to their discharge care plan. They ensure that patients have filled their prescriptions and are taking their medications properly, that they have the medical equipment they need, and that they are able to attend follow-up appointments. As needed, they perform nursing triage for active symptoms, referring patients  to in- and out-patient providers. They work closely with interdisciplinary care management teams at the hospital where the patient was treated and collaborate with ambulatory teams, home health agencies, and community-based service organizations.

According to TOCC data from January 2017 through November 2018, nurses had 6,290 patient interventions that involved providing educational resources and reinforcing overall discharge instructions, and 1,013 interventions that resolved medication needs. They also helped escalate the management of active symptoms for 825 patients.

“No matter how well the discharge team explains next steps of care, patients often do not fully understand or remember what to do,” says Ms. Colgan. “This is pervasive across the entire patient population, regardless of education or language proficiency or socioeconomic status. At Mount Sinai, we understand that they may be overwhelmed with new directives.”

Mount Sinai is one of the few facilities in the country with a dedicated team of on-staff nurses whose full-time job is to call patients. “Our success lies with our registered nursing team,” says Amanda Anderson, MSN, MPA, RN, Associate Director of Care Transitions for the Mount Sinai Health System. “The TOCC nurses are highly trained by Health System service-line leaders. They understand the Mount Sinai culture of putting patients first, and they collaborate with other hospital staff on the patient’s behalf when necessary.”

“It’s great when we are able to triage and provide a service to someone who really needs it,” says TOCC Senior Nurse April Schott-Auerbach, MSN, RN, CNL. “One of my patients was experiencing increasing shortness of breath and it was clear he needed assistance but was unable to get to an urgent care facility or go back to the emergency room. I was able to triage and collaborate with the Health System Community Paramedicine team, which provided the patient with the more immediate assessment he needed.”

According to Ms. Schott-Auerbach, patients are happy knowing that someone is following up with them. One of her patients told her, “I never had such amazing service from other hospitals. It really makes me feel like Mount Sinai cares about me.”

A team picture: The Transitions of Care team.