Kareen Thomas, RN, BSN, CMSRN (left), Wendy Cespedes, RN, MSN, AGPCNP-BC, Kareen Elie, RN, MSN

When patients are discharged from the hospital, they face a critical point in their care. This transition from the acute care to the at-home setting can be especially challenging for two populations: patients with certain high-risk diagnoses and those with social circumstances that create barriers to the care they need. Both are at higher risk for experiencing complications and being readmitted to the hospital.

Enter the nurses of the Mount Sinai Transitions of Care Center (TOCC).

One of only a few teams of its type in the country, the TOCC is a centralized, telephone- and video-based discharge program staffed by Mount Sinai registered nurses, each specially trained in hospital discharge protocols and focused on heading off potential complications and readmissions. Research has identified patients with certain diagnoses, such as heart attack, sepsis, and pneumonia, as being at a higher risk for readmission. Within 24 to 72 hours after these higher-risk patients leave a Mount Sinai Health System hospital, a TOCC nurse calls them to check in, review the discharge plan of care, and identify and resolve any issues or barriers to care.

“Our nurses reach out to our higher-risk Mount Sinai patients as soon as they’re settled at home,” says Kareen Elie, RN, MSN, Clinical Nurse. “Literally overnight, these patients are no longer receiving round-the-clock care and are on their own, so it’s a critical time to get them on track—to confirm they have their medications and are taking them correctly, their in-home care is set up, they understand the symptoms they should be looking for, they’ve scheduled their follow-up appointments and have transportation lined up, and so on.”

The TOCC nurses refer to a set of focused checklists and the notes from the social worker’s pre-discharge patient interview to guide their conversations. However, as Ms. Elie notes, “It’s impossible to predict what direction the conversation might take. Often, the patient has a good understanding of their condition and care, while other times, they haven’t yet picked up their prescription—important medications they need—and the conversation takes a new direction: The troubleshooting and health educating begins.”

Oftentimes, care can be interrupted by a simple breakdown in communication.

“When they’re being discharged, patients are focused on just getting home,” says Kareen Thomas, RN, BSN, CMSRN, Clinical Nurse. “Even with thorough education and printed information about their condition in hand, patients can often feel overwhelmed or confused about their ongoing care and miss something.”

For example, she recently reached out to an older patient with chronic obstructive pulmonary disease (COPD), who had been discharged with several new medications, including albuterol in little nebulizer packets. This is the best method for opening the lungs to help with breathing.

“When I asked about the medication, she shared that she hadn’t been taking it—she ‘didn’t have the machine,’” Thomas  says. The pharmacy hadn’t included a nebulizer with her prescription, and she didn’t understand how important this was to her treatment and didn’t know who to call or how to get one.”

Ms. Thomas was able to address the situation with a few phone calls, but noted how a simple barrier can lead to a bigger problem.

“Without this treatment, the patient would continue to have coughing fits and shortness of breath and would be suffering, and in a matter of days would end up in the Emergency Department with COPD exacerbation,” she explains.

Likewise, the TOCC nurses are aware that a care plan may not always go as planned.

In one extreme case, Wendy Cespedes, RN, MSN, AGPCNP-BC, Clinical Nurse, placed a follow-up call to a patient who had been discharged on a particular antibiotic. As they spoke, the patient began to describe some unusual symptoms, including suddenly not being able to walk up or down stairs. Ms. Cespedes consulted with colleagues, did some quick research on the medication, discovered a related black box warning, and suspected he might be experiencing a very rare side effect. She shared her findings with the patient’s physician, who immediately changed the patient’s medication, potentially saving his life.

Helping Patients Overcome Social Barriers

For another population of patients, it is the circumstances of their life, known as “social determinants of health,” that can influence their health and well-being.

“For many patients, the conditions within the environment in which they live, work, play, and age can contribute to poor health outcomes and health disparities,” says Esther Pandey, DNP, MS, RN, Vice President of Care Transitions for the Mount Sinai Health System. “This can determine the quality of the air they breathe, their access to transportation or healthy food or specific medications. It can determine their English proficiency and their ability to understand their medical condition or care plan. It can dictate their support network. All of this has the potential to negatively impact a patient’s health and well-being after discharge.”

“As nurses, we are in a unique position to identify and address these potential social-driven barriers that can prevent patients from achieving optimum health.”

Ms. Cespedes witnessed this impact firsthand.

“My mother is primarily Spanish-speaking. When my sister was young, she had a serious medical condition and didn’t get the help she needed because of miscommunication. The providers interacted with my mother but without a medical interpreter. This language gap created a huge barrier to care and is what motivated me to become a nurse and help the underserved in my community.”

For example, many of the patients she interacts with are older and not originally from the United States.

“They don’t understand their diseases, their symptoms, or the need for a lifestyle change, and many live alone without access to help they might need,” Ms. Cespedes says.  “Through the TOCC, I’m in a position to get these patients started with the help and the medication they need, to educate them about their health, diet, and nutrition. It’s such a privilege.”

Ms. Thomas shares these sentiments.

“As part of our regular interactions with patients, we now ask social determinants of health-related questions,” she says. “Do they fully understand their condition and how their choices around diet and exercise or taking their medications properly can impact their health? Are they struggling with finances, have trouble paying their rent, electric bill, or for groceries or medications, or choosing between one or the other? The copay for some medications can be as much as $600, which the average person can’t easily afford.”

In these cases, the TOCC team can access a variety of resources the patient might otherwise not know about, including finding online pharmaceutical coupons or working with the physician to find an alternative medication with a far lower copay, helping patients apply for food assistance or home delivery, or securing a referral for a home health aide.

“Sometimes these patients just need someone to raise these issues at the right time,” says Ms. Elie. “They may be more comfortable or more focused when they’re at home, so they may be more receptive to the information. It’s a great feeling to be there for them, to guide and advocate for them, and to know you made a difference in the quality of their lives.”

“This is a phenomenal team of nurses, and the importance of the guidance, help, support, and advocacy they provide our patients cannot be overstated,” says Dr. Pandey. “Literally, every day they are making a difference in the quality of someone’s life.”

Tracy Bertiz, DNP, ACNP-BC, CHFN

The Center for Nursing Research and Innovation at Mount Sinai recently interviewed Tracy Bertiz, DNP, ACNP-BC, CHFN, Nurse Practitioner at Mount Sinai Fuster Heart Hospital, about her quality improvement initiative, “Improvement of Nurses’ Ability in Addressing Low Health Literacy to Reduce Hospital Readmission in Adult Heart Failure Patients.” Presented as a poster at Nursing Research Day 2023, the findings were published last month as an abstract in the journal Practical Implementation of Nursing Science. 

What sparked the idea behind your project?

As a Cardiology Nurse Practitioner, I’ve always considered the frequent hospital readmission of our heart failure patients a big challenge. We call them our “frequent flyers.” We have multiple initiatives addressing this issue, but the readmission rate has remained high in spite of our best efforts. Since health literacy can play a large role in the gaps in care experienced by heart failure patients, my project team and I decided to teach nurses and other care team providers how to assess health literacy, and how to use targeted communication strategies to help patients better understand discharge instructions. We chose to work with staff at Mount Sinai’s Transitions of Care Center (TOCC) because of their important connection to patients as they move from one setting to another. Our goal was to decrease the 30-day heart failure readmission rate by training the care team to first assess the health literacy of their patients, and then to offer practical discharge instructions tailored to each individual’s level of understanding. We found that patients benefitted from their care providers using simple language, which helped them develop self-efficacy and better navigate the health care system.

*The above is a sample from the virtual training.

How did teamwork help make the project a success?

The TOCC team was a catalyst for change, and the teamwork we built helped us achieve remarkable results. Additionally, the commitment of the TOCC to close the gaps in care for patients transitioning from hospital to home helped make this project sustainable. I want to acknowledge my Doctor of Nursing Practice (DNP) project team, Tara Cortes, PhD, RN, FAAN, and Chenjuan Ma, PhD, RN, at the NYU Rory Meyers College of Nursing. Their constant mentoring helped me succeed in this endeavor. I also want to recognize the leadership and staff at the TOCC: Esther Pandey, DNP, MS, RN, System Vice President of Care Transitions; Carl Jin, MSN, MPA, RN, Director of Clinical Services; Arzellra Walters, MA, CPNP, RN, Nurse Manager; and the Center’s fantastic nurses. They were instrumental in implementing the initiative. This project would not have materialized without them.

What have you learned from your project?

I have learned that TOCC nurses play a significant role as frontline health care coaches for patients across the Mount Sinai Health System. Effective communication is critical to patients’ adherence to their medications, regular follow-up with health care providers, and self-care of chronic medical conditions.

What new ideas are you hoping to pursue after this experience?

I want to continue to gather and share insights about the importance of assessing health literacy in all patients, regardless of their educational background. Awareness of health literacy can enable care providers to communicate more effectively, but this is only one part of the equation. I think it’s also important to assess patient self-efficacy after receiving instructions targeted to their health literacy level. I would like to investigate whether particular methods of teaching are effective in driving change in patient outcomes.

What advice would you give other Mount Sinai nurses who are thinking of starting a similar project or submitting an abstract?

Mount Sinai nurses who want to start a project must be passionate about their topic to sustain their effort through the intervention period and beyond. Getting other people involved is difficult if your project does not add value for them, so you need to offer something to generate “buy-in” from all the stakeholders involved. In addition, you need to have a clinical mentor who cares about the outcome of your project, and you have to take advantage of the resources available at Mount Sinai, such as the Nursing Project Approval Council at the Center for Nursing Research and Innovation.

Joseph Krivoruk, BSN, CCRN

Joseph Krivoruk, BSN, CCRN, is a critical care nurse in the Intensive Care Unit (ICU) at Mount Sinai Brooklyn. During his 10 years at the hospital, he has witnessed the death of patients in his care. He is often the first health care provider a deceased’s family encounters, so he has played an important role consoling family members and offering emotional support. But Joseph long felt he wanted to do more. “I wanted families to know that although it isn’t our family member, we, as staff on the unit, understand the sadness and frustration, and we sympathize with their loss.”

The seed for an idea to do more was actually planted 14 years ago, when Joseph’s grandmother passed away from a brain hemorrhage and he was given a copy of her last CT scan. “Giving families something tangible to remember their loved one by seemed meaningful, it felt right.”

Through the spring and summer of 2023, Joseph and his family had a series of ailments and losses. During this time, he came across another hospital that gave a similar “take home” gift to families of children in the ICU. He shared his thoughts about such a gift with his manager, Jacqueline Callender, MPH, CCRN, and the Director of ICU, Ilse Martinez Espina, MD. In October 2023, the first “Message in the Bottle”—a printout of a patient’s last good heart rhythm, placed in a small bottle with a sympathy note—was given to a family member, and was positively received. The family appreciated being able to hold onto their loved one’s last heartbeat.

Message in a Bottle keepsake

Joseph’s journey into his current role hasn’t been straightforward. He began his career as an emergency medical services professional and eventually entered nursing school. “When my grandmother was ill, it became clear to me that nursing care is about dignity and safety.”  His first nursing job was in home care hospice, where, Joseph says, these lessons of dignity and the values of acknowledging family, were reaffirmed. They are, he says, among the personal life lessons he often shares with nursing students and newly hired nurses at Mount Sinai.