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Bridging Gaps with Patient-care Transitions during the COVID-19 Pandemic

by Jen Volland, VP Program Development, NRC Health


During times of change, it can be difficult to stay consistent with previously established patterns of improvement. When new steps that didn’t exist before are introduced into processes, it’s analogous to adding another variable into an equation that didn’t exist previously and was left unaccounted for—it can have a positive impact, or a negative one.

The coronavirus is impacting hospitals greatly, whether they’re currently working through the epidemic or gearing up for what may be ahead. Many hospitals have been stretched to their limits, and as a result it’s inevitable that some things will drop off as our heroes—nurses, doctors, pharmacists, lab technicians, environmental-service professionals, and others—are not only increasingly drawn to the frontlines, but are also needed for extended periods of time and extra shifts. Some tasks that typically reside with nursing may need to change in the interim, to free up adequate staff.

NRC Health’s Transitions program leverages technology to help identify those patients most in need of help in the critical 24–72 hours post-discharge. It does this by reporting patient-level assessment data, so that patients’ issues can be quickly and efficiently resolved by the care team. Tracking, trending, and benchmarking data isolates key areas for process improvement, allowing organizations to make the necessary changes to reduce future readmissions and ensure a safe transition for all patients.

The connective lifeline between the patient, a phone call, and providers

For patients who receive a care-transition call, not receiving follow-up can lead to unnecessary stress, attempts to utilize the Emergency Department for unresolved items, or being unable to successfully manage their care at home. Furthermore, some of the patients being called are in the category classified as high-risk for the coronavirus, and locations such as urgent-care and emergency departments are not currently safe places for them to get assistance, especially if it can be done over the phone after they are identified with a post-discharge need. To maximize the use of NRC Health’s Transitions program during the coronavirus pandemic, we encourage the following:

  1. Be aware. Are follow-up calls to patients who are flagged as needing them still being completed? It’s important that this question be asked as a review of the alert-resolution completion level, and not coupled with blame. Staff are presently doing everything they can on the frontlines, and even priority concerns can easily get sidetracked—sometimes without anyone realizing it.
  2. Assess. If the organization utilizes a model in which nurses on the frontlines are conducting return calls to patients who are identified as needing help, who’s able to temporarily take over this function while nurses tend to acutely ill patients within the hospital? Depending on the types of alerts that are being triggered the most, it may make sense to look to other professionals who have knowledge of discharge resources, such as medical social workers.
  3. Act. Failure to act is an action—and there’s more than one way to structure discharge-call follow-up to ensure that it’s completed. East Tennessee Children’s Hospital allocates the call-back process both to nurses and to the patient-experience department, depending on the follow-up need. This helps split the responsibility between the two areas, so fewer patients fall through the cracks. If nurses are stretched to a premium, have alternative people in place who are able to take over follow-up calls in the interim.

Following up with patients who have identified an additional need after a hospital stay is more important than ever before, given the present pandemic. Patients already receive a lot of information while in the hospital, and with the added stress of this unprecedented situation, they may find it more difficult to retain that information. Using NRC Health’s Transitions program allows your organization to reach out to 100% of post-discharge patients to determine if, when, and where they need to seek care to resolve any lingering concerns. Beyond a promise to our patients to do our very best, care-transition calls can help serve as an intermediary to help keep patients from returning to the hospital if it isn’t absolutely needed, and enable them to practice effective social distancing for their own well-being and that of others.

To obtain more information about NRC Health’s Transitions program, and to help your organization ease the resources required for reaching 100% of patients post-discharge, contact info@nrchealth.com.