Woodlawn Hospital earns Exemplary Practice status for successful TCM implementation

Wednesday, November 13, 2019

The Great Lakes Practice Transformation Network (GLPTN) recognized Woodlawn Hospital (“Woodlawn”) of Rochester, Ind., as an Exemplary Practice for its implementation of Transitional Care Management (TCM) services as part of the Centers for Medicare and Medicaid Services-funded Transforming Clinical Practices Initiative (TCPi). To be designated as Exemplary, the organizations were required to make notable improvements in practice assessment and achieving TCPi Level 4; to demonstrate improvement in clinical quality measures; and to embrace a patient-centered culture.

Woodlawn Hospital awarded Exemplary Practice status by GLPTNWhat is Transitional Care Management?

When patients transition between care settings, they are at increased risk for adverse events, and this is especially true in the geriatric population and when patients have multiple chronic conditions. Many times, patients leave the hospital after an acute care episode only to return home with little or no support. Once home, they need help understanding their medication changes and discover limits to the activities of daily living.

TCM comprises a broad range of services to promote a safe, medically supervised handoffs between levels of healthcare across care settings. TCM ensures patients are transitioned from the emergency room or hospital back to the community without the risk of readmission or an adverse health result once they get home. With TCM, medications are verified and care gaps are addressed immediately following hospital discharge, creating a seamless process for the patient.

Addressing patient needs post-discharge

Late in 2017, it became clear to the quality team at Woodlawn that its patients were missing the benefits of TCM and its absence was causing some unnecessary hospital readmissions within a month of the patients’ discharge. While the Woodlawn team had made strides to increase patient satisfaction during the hospital stay, they felt the hospital needed to do more to address patient satisfaction outside that time frame. To ensure patients have what they need to successfully continue their recovery at home, the rural healthcare provider began to work with GLPTN Indiana under the direction of Purdue Healthcare Advisors (PHA) to reduce unnecessary hospitalizations by targeting the TCPi objective of “promoting care coordination between providers of services.”

Having instituted a similar process at a different facility, Woodlawn’s Director of Physician Services Lisa Vogler was aware TCM could meet the team’s objective. She also recognized that TCM required accurate documentation, and asked Clinical Informatics Coordinator April Lyn Grubb, LPN, to create templates in the hospital’s electronic health records (EHR) system to ensure all pertinent questions were asked, answered, and documented as required by TCM standards. 

Implementing TCM

Like other rural healthcare providers with limited resources, the Woodlawn team found the financial impact of adding a new program to be a struggle, but was convinced that TCM could provide the high-quality care they sought as well as provide cost savings for the hospital. Once the process was designed and administrative approval granted, Vogler and Grubb collaborated with department heads, trained key team members in the medical/surgical unit, and hired a registered nurse to focus solely on the TCM process in the newly created position of clinical care coordinator.

Woodlawn’s post-discharge process now requires the coordinator to schedule a TCM appointment with the appropriate Woodlawn provider when the patient is ready to leave the hospital, at which time the coordinator and provider create a patient action plan. Upon review of hospital and outpatient medical records, the coordinator calls the patient and/or caregivers at home 24 to 48 hours post-discharge. Using a template, the coordinator determines how the patient is doing at home. She asks whether the patient has any concerns, and determines if they have the appropriate help at home for their situation. The coordinator also reviews the patient’s medications in detail.  Following the call, the coordinator documents the findings in a message sent to the provider, who reviews the information and makes care decisions quickly, if needed. Dependent upon the level of care needed, the patient is seen in the provider’s office between 3 to 14 days post-discharge.

Impact of the new TCM process

Within the first six months, the Woodlawn team made some “great catches” with regard to post-discharge patient care. One instance involved an elderly man who had been in and out of the hospital quite a bit. He lived alone and had no real assistance at home. When the first nurse to take on the TCM Clinical Care Coordinator position, Kristina See, RN, called the man to check in post-discharge, she found him extremely confused and taking the wrong medications. She spent a couple hours talking him through his post-discharge instructions and medications, but realized that he was headed for another hospital stay if he didn’t receive provider assistance right away.

The coordinator immediately consulted his primary care provider and was able to schedule the patient for a  same-day TCM appointment. At the appointment, the provider was able to implement a plan to prevent the patient’s readmission as well as provide him with better quality of life at home. The coordinator and physician worked together to set up home health services and a prescription service that packaged the patient’s medication in a day/time package to eliminate confusion, at no additional cost. In addition, they connected the patient with community resources for help with meals, temporary housekeeping, yardwork, and emotional support.

The current Clinical Care Coordinator, Michelle Jackson, RN, enjoys connecting with the patients. Her involvement in their care has resulted in a better path to recovery, a reduction in hospital readmissions, and improved quality of life after hospital stays. Specifically, Woodlawn’s 30-day, all-cause readmission rates were reduced from 14% in 2017 to 2.81% through the third quarter of 2019. In addition, the implementation of TCM services in April of 2018 not only positively affected the lives of the patients served, but created a positive financial impact for the organization.

How can patients be proactive with TCM?

Under TCM, the patient’s primary care provider (PCP) closely monitors and supports the patient to ensure that their health is stabilized and that they have necessary medications, community resources, and home assistance they need. Because the PCP’s role is essential to successful TCM,  Vogler advises patients to be proactive about their transition from the hospital by:

  1. notifying their PCP immediately upon hospitalization so that the provider can follow their progress;
  2. ensuring that the discharging facility knows the name of their PCP in order to forward on patient records upon discharge;
  3. contacting their PCP upon discharge or as soon as they get home so that they can schedule a hospital follow-up visit(s); and
  4. attending the hospital follow-up visit(s) to ensure the best health outcome.

List of GLPTN Indiana-designated Exemplary Practices


PHOTO CAPTION (shown from left to right): Woodlawn Hospital's CEO John Alley; Director of Physician Services Lisa Vogler; and Clinical Informatics Coordinator April Lyn Grubb, LPN.


Writer: Polly Malloy, 708-217-3019, pmalloy@purdue.edu

Tags: Quality Services

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