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Rowe creates successful Transition of Care program to improve hospital readmissions

Rowe creates successful Transition of Care program to improve hospital readmissions

December 03, 2014 at 9:46 AM

One of the core values of the RV Difference is to focus on and empower the patients and employees.  Social Worker Elanderia Rowe at Carrollton, used this core value as a guiding principle to develop and implement RV Team Linked Care (TLC) for prevalent patients. 

RV-Innovation-Print-Ads.jpgThe RV TLC program started in March 2013 with a primary focus of reducing hospital readmissions through the use of staff and patient engagement and 2-way communication with the hospitals. The program seeks to improve communication with hospitals that refer to RVM dialysis centers by building relationships with those hospitals, gaining access to the patient’s EMR, and standardizing the process for transference of post-hospitalization medical records, including discharge instructions.

Prior to graduating from RV Impact Leadership program in 2013, Rowe and three other program members delivered a project proposal “The Usage of Medical Technology to Address Fluid Management” to the RVM executive team. While researching for the proposal, Rowe discovered a significant need for the improvement in the transition of care for dialysis patients. When asked to serve on the RV Innovation committee the following year, Rowe used this research to develop processes and procedures for RV TLC.

Another part of the program encourages patients and staff to use the tools developed by the Joint Commission and ESRD network, "Speak Up," "Teach Back" and "Health Literacy," which aim to improve patient and staff relationships and empower patients to take a more active role in their health care.  Implemented at the Carrollton, Plano and Lewisville clinics, patients and staff members have been able to see data indicating the effectiveness of RV TLC and the outcome of their efforts. 

Regarding the patient "Speak Up" process, Rowe said, "We used out of the box thinking and strategies to get patients comfortable asking questions.  We gave patients a list of questions that they could ask their nephrologist during rounds and encouraged them to ask questions even if they already knew the answer to the question." To encourage participation, after patients asked questions, their name was place in a drawing and after each rounding session a drawing for a prize took place. Prizes were simple but effective, such as a candy cane attached to a bottle of root beer with a ribbon.   

RV-TLC-Celebration_story_blog.jpgSo far the program has been a success with a decrease in the number of hospital readmissions when the clinic uses the tools and follows up with the patient.  Hospitals have also been enthusiastic about the program and asked Rowe to present it to other hospital locations. 

"When we presented our program to them they were very much on board.  One hospital called their hospitalists and medical directors and we presented to program to them as well," Rowe said.

The program was also mentioned in a recent RVM advertisement.  Rowe and the Carrollton clinic recently celebrated its mention and successful rollout. 

Looking ahead, the current plan is to move forward with the TLC program by rolling it out to selected RVM centers.  "We've had to revamp some processes and streamline some things, but overall it has been a huge success," said Rowe.



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