Award-winning Deaconess Transitions of Care Team supports patients’ success beyond the hospital

Returning home after a hospital stay can be a difficult time for patients: Medication regimens often change. Self-care responsibilities tend to increase, and discharge instructions may be complex. If patients don’t have support or adequate follow-up care, they can experience poor health outcomes and end up back in the hospital.

Meghan Roberts, MD, medical director for MultiCare’s Inland Northwest hospitalists*, saw an opportunity to help ease that shift from hospital to home by launching the Deaconess Transitions of Care (TOC) Team, winner of the 2021 President’s Award for Excellence in Population-Based Health. This annual award series honors excellence and achievement through teamwork at MultiCare.

“Our goal is to set patients up for success,” says Dr. Roberts. “No matter what their individual situation is, we want patients to feel secure when they leave the hospital. We want them to know there’s a follow-up plan in place and people they can turn to for help.”

The life of a care coordinator

At the heart of the TOC team are three transition care coordinators, one of whom is Sara Zeigler — and she describes working on this team as her “dream job.”

Zeigler’s workday begins with patient rounds: She and her fellow coordinators meet with every patient who is in the care of a hospitalist within the first 24 hours of their admission to MultiCare Deaconess Hospital.

“That initial interaction is important,” says Zeigler. “Some patients feel really lost and scared, like they’re never going to get better, so we focus on building trust, learning about who they are and letting them know that someone cares about what happens to them even after they leave the hospital.”

After that first meeting, Zeigler and her colleagues work closely with people throughout their entire inpatient experience to help prepare them for the transition to the next location, whether that’s home or another level of care, such as a skilled nursing facility.

What this preparation looks like varies depending on the needs of each individual. One of the team’s main goals is to ensure that no one leaves the hospital without a scheduled follow-up appointment with their primary care provider (PCP), and if someone doesn’t have a PCP, the team hooks them up with one.

“Having that follow-up care in place not only helps patients but also gives their hospital physicians peace of mind too,” says Dr. Roberts. “It’s reassuring to know patients have support in place to help prevent readmission, and sometimes it can allow us to discharge people earlier than expected.”

In addition to creating a plan for follow-up, the care coordinators connect people who may have basic unmet needs, such as housing or access to nutritious food, with community resources. They also identify and troubleshoot problems that may interfere with a patient’s success upon discharge.

“Sometimes people can’t afford medications or devices like walkers or wheelchairs,” says Zeigler. “Or sometimes they don’t have a way to get to their follow-up appointments, so we find creative ways to overcome those barriers.”

For example, Zeigler recalls one patient who was afraid to leave their house and didn’t have access to a phone. The team used some of their President’s Award winnings to provide this patient with a pre-paid mobile phone so they could still participate in follow-up telehealth visits and had a way to reach out in case a problem arose.

Other patient barriers require more brainstorming and behind-the-scenes teamwork. For example: A patient with a leg wound is ready for discharge but they live alone, and their house has a lot of stairs, which could make recovery problematic. In cases like these, the team will work with other groups within MultiCare, such as case management and social work, to identify other options so the patient isn’t stuck in the hospital for longer than necessary.

Even after a person is discharged, care coordinators remain involved. They serve as the main point of contact for patients once they leave the hospital, answering questions and escalating issues as needed. The team fields approximately 15 to 20 calls a day from patients and families who need extra support.

“Patients are just so relieved, sometimes to the point of tears, that they have a team to turn to for whatever they might need once they are outside the hospital,” says Sara Welty, DNP, manager of the TOC team. “Every day we hear about what a difference this program makes in people’s lives.”

It’s all about partnership

Since April 2021, the TOC team has served almost 4,300 patients. Their success hinges upon strong partnerships across departments and entities within MultiCare, as well as with other local organizations, such as the Community Health Association of Spokane (CHAS). This nonprofit provides primary care and other types of care to individuals experiencing homelessness. Approximately 17 percent of the patients the TOC team serves also receive care through CHAS.

“Part of what makes this work so rewarding is that we come together with our partners — whether it’s CHAS or MultiCare Rockwood Clinic or another health system like Providence — to do what’s right for our patients, and that benefits the whole community,” says Kirsten Young, regional hospitalist supervisor, who leads the team along with Welty and Dr. Roberts.

Looking to the future, the TOC team plans to grow that network of community partnerships in addition to expanding the program’s scope to all patients at Deaconess, not just those in the care of hospitalists.

“Ideally, says Dr. Roberts, “We’d like every patient who leaves the hospital, from those seen in the emergency department to those here for a scheduled surgery to have the opportunity to work with our care coordinators and have a unified follow-up plan.”

*Hospitalists are doctors that treat a variety of illnesses and injuries and work exclusively in a hospital setting.