Developing a Rural Transitional Care Community Case Management Program Using Clinical Nurse Specialists

Purpose: This quality improvement project developed a community nursing case management program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, if needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority. Background: As more people reach Medicare age, the number of individuals with worsening chronic diseases with dramatically increases unless appropriate disease management programs are developed. Rationale: Care transitions can result in breakdown in continuity of care, resulting in increased preventable readmissions, particularly for indigent patients. The CNS is uniquely educated to managing care transitions and coordination of community resources to prevent readmissions. Description: After a thorough SWOT (strengths, weaknesses, opportunities, and threats) analysis, we developed and implemented a cost-avoidance model to prevent readmissions in our uninsured and underinsured patients. Outcomes: The project CNS used a wide array of interventions to decrease readmissions. In the last 2 years, there have been a total of 22 less than 30-day readmissions to the emergency department or hospital in 13 patients, a significant decrease from readmissions in these patients prior to the program. Three of them required transfer to a larger hospital for a higher level of care. Conclusion: Using advanced practice nurses in transitional care can prevent readmissions, resulting in cost avoidance. The coordination of community resources during transition from hospital to home is a job best suited to CNSs, because they are educated to work within organizations/systems. Implications: The money we saved with this project more than justified the cost of hiring a CNS to lead it. More research is needed into this technology. Guidelines for this intervention need to be developed. Replicating our cost-avoidance transitional care model can help other facilities limit that loss.