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.”
