title: A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond.
abstract: BACKGROUND
  In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%.
  
  
  OBJECTIVE
  To examine the impact of the McGuire VAMC TCP on Veteran ED and hospital utilization and costs.
  
  
  METHODS
  Veterans being discharged to home following an inpatient admission, ED visit, and/or short rehab stay.
  
  
  METHODS
  The primary means of identifying patients for the program is through daily screening of the previous 24-hour admission and ED report, which the inpatient nurse practitioner performs. She completes an extensive review of each Veteran's electronic medical record to determine the number of ED visits and inpatient admissions at the VAMC and in the community. Initial criteria for consideration in the program included the following: more than two hospital admissions and/or ED visits in the past 90 days or at high risk for readmission based on a Care Assessment Need score of greater than 95. Two hundred Veterans participated in the program in fiscal year (FY) 2013, with 146 participating in FY 2014. A retrospective chart review of Veterans participating in the TCP in FYs 2013 and 2014 was conducted, with a focus on number of admissions and ED visits 90 days prior to admission to the TCP and 90 days following TCP admission. Average admission and ED costs for this VA were calculated to determine cost savings from pre- to post-90 days of admission and ED visits.
  
  
  RESULTS
  Veterans who obtained TCP services in FYs 2013 and 2014 experienced a 67% decrease in hospital admissions and a 61% decrease in ED visits in the 90 days following participation in this program compared with the 90 days prior to participation. This produced an estimated net savings of $3,823,673 in medical center costs. In addition, registered nurse case managers (RN CMs) noted improved patient compliance and satisfaction with care and the licensed clinical social worker noted reduced caregiver burden.
  
  
  CONCLUSIONS
  The results of this program demonstrate how using an interdisciplinary approach to develop patient-centered transition plans of care through intensive case management interventions improves resource utilization with substantial financial savings. This program represents a feasible option for other VAMCs as well as civilian hospitals seeking to provide cost-effective transitional care to patients upon discharge and prevent untimely readmissions. With an RN CM at the hub of patient care, this program successfully demonstrates the value of smooth care transitions.
authors.affiliation: Derenda Lovelace, MSN, RN-BS, Cm, is the Geriatrics and Extended Care RN Navigator at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. She has been an RN for 37 years and a Case Manager for 22 years for the Federal government in the Department of Defense as well as the Veterans Administration in Medical Management and Case Management. Diane Hancock, MSN, RN, GNP-BC, is a certified geriatrics nurse practitioner serving on the Transitional Care Team and managing a caseload in Geriatric Clinic at the Hunter Holmes McGuire Veterans Administration Medical Center in Richmond, Virginia. She has been a nurse for 32 years specializing in Critical Care Nursing for 24 years prior to becoming an NP. She has also worked in private practice in Internal Medicine and Long-Term Care. Sabrina S. Hughes, MSN, RN, is an RN case manager in the Transitional Care Program at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. She has been an RN for 13 years with a focus of educating patients on preventative health measures. She is currently enrolled in a Family Nurse Practitioner program and scheduled to graduate in June 2016. Phyllis R. Wyche, FNP-BC, MSN, RN, works in Geriatrics and Extended Care as the NP for the Inpatient Transitional Care Program at the Hunter Holmes McGuire Veterans Administration Medical Center in Richmond, Virginia. She has been an RN for 34 years and an NP for 17 years with a focus on inpatient medicine and geriatrics. Claire Jenkins, PharmD, BCPS, is the Transitional Care Program Clinical Pharmacy Specialist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. After graduating from the South Carolina College of Pharmacy, she completed her PGY-1 Residency at the McGuire VA Medical Center. Cindy Logan, LCSW, provides psychosocial assessments and assists Veterans in accessing needed community services and Veteran benefits in the Transitional Care Program, Home Based Primary Care and Mobile Medical Unit at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. She has been a social worker for 15 years specializing in community mental health specifically crisis work.
authors.forename: Derenda
authors.initials: D
authors.lastname: Lovelace
authors.forename: Diane
authors.initials: D
authors.lastname: Hancock
authors.forename: Sabrina S
authors.initials: SS
authors.lastname: Hughes
authors.forename: Phyllis R
authors.initials: PR
authors.lastname: Wyche
authors.forename: Claire
authors.initials: C
authors.lastname: Jenkins
authors.forename: Cindy
authors.initials: C
authors.lastname: Logan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care; D000069341:Transitional Care / Q000458:organization & administration*; D014768:Virginia