To lower readmissions, City of Hope trains others in postdischarge care

June 18, 2015 | by Jon Thurber

If there is one truism about hospital stays it is that patients want to get out. For many, however, the joy of being discharged is tempered by the unexpected challenges that recovery in a new setting may pose.

training to reduce hospital readmission Leaving the hospital is but one step on the road to recovery. To ensure that recovery continues, at-home and professional care workers need to be properly trained. That's where City of Hope's Transition of Care program comes in. It aims to reduce hospital readmissions.

Even with professional help, the quality of care and treatment that patients receive at City of Hope is hard to replicate in the home or even in a professional care facility. Readmission to the hospital may be required to attend to issues that might have been resolved had the original posthospital care been more thoughtful; the training a bit more comprehensive.

That was the situation that Brenda Thomson, City of Hope’s director of case management and village operations, observed about two years ago when she began looking at patient readmissions.

“What City of Hope does far exceeds what [patients] get at other places,” Thomson said. “[Patients] may leave with quite extensive drains, wounds and medication regimens.”

She looked at the situation and found that some care providers had gaps in their procedures when it came to treating patients with specialized needs. And these were not just in-home care providers. She found this was also the case at long-term acute facilities, skilled nursing facilities, acute rehab and hospice care.

So Thomson began developing a training program to remedy the situation. Led by City of Hope, the program is now called the Transition of Care Community Coalition and includes 35 of the leading transitional health care organizations, with 90 individual participants, from Los Angeles, Riverside, San Bernardino and Orange County counties.

'We started with one agency ...'

Thomson said these organizations share a “like-minded vision and values for ensuring safe transitions from one level of care to another.”

The training program began small, Thomson said. “We started with one agency and taught everyone we could, and once they gained competence, they passed along the training to others within their organization. That became our model."

Now, City of Hope hosts quarterly meetings of coalition members as well as occasional informal sessions. The formal meetings run one to two days — the next meeting is scheduled for September — and includes discussions on a wide array of best practices. These issues may include the handling of specialized treatments for stem cell transplants to complex IVs to colostomy maintenance.

And while other hospitals or health care providers may have similar programs, Thomson noted that they are mainly focused on training personnel at skilled nursing facilities. By contrast, “we’re trying to train everybody,” Thomson said, “including home health care agencies, home infusion companies, skilled nursing facilities, long-term acute facilities and acute rehab facilities. We’re taking it further by including the broader community.”

The right training at the right time

This enhanced training comes at a key time in the health care industry, as more complex surgeries and procedures are being done on an outpatient basis.

Mastectomies, stem cell transplants and chemotherapy are now often done without a hospital stay, something that was unthinkable a generation ago. In addition, national projections show that the incidence of cancer is rising, with population growth and an aging segment of baby boomers contributing to the increase.

With outpatient treatment increasingly the option of choice, postprocedure training in the community is a vital component to patient recovery.

Thomson said that this kind of training is already producing results, in the reduction of readmissions to City of Hope for seemingly routine after-care issues.

“City of Hope — as a leader in cancer care and research — has an obligation to do what it can to address the needs of this population,” Thomson said. “We feel that this work contributes significantly to improving the health of our community.”

One of the points she learned early on dealing with patients at City of Hope, Thomson said, “is that they are very protective of their care.” If a caregiver either in the home or in an after-care facility does something in a different way, the patient may say: “That’s not how City of Hope does it."

“We need to do everything we can to make the patient comfortable with their level of care,” she added.

More information on the Transition of Care Community Coalition may be obtained contacting Thomson at [email protected]


Learn more about becoming a patient or getting a second opinion at City of Hope by visiting our website or by calling 800-826-HOPE (4673). You may also request a new patient appointment online. City of Hope staff will explain what's required for a consult at City of Hope and help you determine, before you come in, whether or not your insurance will pay for the appointment.

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