Optimizing Care Transitions for Minimally Invasive Radical Cystectomy Patients to Reduce Readmissions and Enhance Recovery Success
Christopher T. Tucci, MS, RN-BC, CURN, NE-BC; Ashlee Viveiros, DNP
Transitions of care between settings can place patients with complex care needs at risk for poor outcomes due to lack of communication and coordination between organizations and caregivers. Shorter length of stays in hospitals means patients are discharged home with increasingly complex needs. Home care agencies are charged with understanding and managing complex patient care at home and fostering patient self-care to prepare for discharge from services. The Minimally Invasive Urology Institute (MIUI) partners closely with preferred visiting nursing agencies, with consideration to patient preference as needed, to standardize the plan of care and share responsibility for successful recovery of minimally invasive radical cystectomy patients. The MIUI provides education to agency staff upon partnership initiation and annually to ensure the plan of care, goals for recovery, and ongoing education needs for this patient population are understood. To optimize coordination efforts, the home health care liaison meets with the patient/family and members of the inpatient care team to obtain a comprehensive handoff and plan for transition to home. This process ensures the agency can plan for a visit frequency schedule that matches the needs of the unique patient situation. The visiting nurse agency nurses communicate pertinent information to the MIUI during each home visit to ensure the patient remains on track toward recovery. These care coordination and patient navigation efforts have demonstrated a reduction in fragmented care across settings for this patient population. The MIUI has seen decreased avoidable readmissions, reduced emergency room visits, fewer complications, and improved communication and continuity of care. The MIUI will continue to monitor these outcomes to reevaluate processes and identify opportunities for ongoing improvement in our care transition program.
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