Lourdes to Enhance Transitions of Care for Elderly with $25,000 Grant from Cardinal Health Foundation

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New transitional care program aims to improve patient safety at point-of-care for most vulnerable populations

Standard discharge practices are often fragmented due to a lack of cohesiveness in the transition process from hospital to home. Lourdes’ goal is to redesign the way we transition our elderly patients through enhanced education, communication and support.

Lourdes Health Foundation has received a $25,000 grant from the Cardinal Health Foundation to support the Transitional Experts in Residence Program at Our Lady of Lourdes Medical Center.

The program, which focuses on training and sustaining safe medication practices to manage and promote the effective transition in care for elderly patients with chronic health conditions from the acute care setting to home, is the only in the state of New Jersey to receive funding from Cardinal’s competitive E3 grant program.

The Transitional Experts in Residence Program project, led by co-directors Ann B. Townsend, RN, DrNP, APN and Maryann Classick-Wallace, RN, BSN, is set to launch this month. The purpose of the program is to support and expand the existing core team of transitional practitioners working towards excellence in transitions of care at Our Lady of Lourdes Medical Center.

The already established multidisciplinary core team, which consists of four direct care individuals—a nurse practitioner, two registered nurses and a pharmacist—is a subset of the larger multidisciplinary Transitional Care Team that has been dedicated to improving all aspects of care transitions since 2009.

“Lourdes is honored to be chosen to receive project funding,” said Dr. Townsend. “With this grant, we intend to further bridge the gap between when an elderly patient is hospitalized and when they are discharged to outpatient care. Through the implementation of the Transitional Experts in Residence Program, we are committed to saving days, dollars and lives through reduced readmissions and the effective, safe transition of our elderly patients.”

The Clinical Transitional Experts in Residence Program is based on current evidence and includes:

  • A formalized education program for the multidisciplinary core team based on the Transitional Care Model.
  • Extended hours and improved patient access to pharmacy team members via electronic tablets for direct consultations with elderly patients considered “at-risk” or “high risk” for medication adversities.
  • The requirement of team pharmacists to attain a Certification in Geriatric Pharmacy (CGP).
  • Support of continued clinical preceptorships of pharmacy and nursing students to enhance the emphasis on safe medication transitions in the elderly.

Through enhanced education of the Transitional Care Model—an evidence-based model that focuses on transitional care for chronically ill older adults and has been shown to reduce health care costs and improve quality of life for high-risk elders—members of the Transitional Care Team such as discharge advocates, case managers and pharmacists will have the knowledge and skills to more effectively prevent avoidable readmissions through transitioning the individual from the care of the hospital team to self-care with community support.

“Standard discharge practices are often fragmented due to a lack of cohesiveness in the transition process from hospital to home. Lourdes’ goal is to redesign the way we transition our elderly patients through enhanced education, communication and support,” added Maryann Classick-Wallace.

The program’s specific objectives include:

  • Reducing 30-day readmission to 9.93 % or less with a plan to increase the number of trained multidisciplinary Clinical Transitional Experts on the team.
  • Reducing the number of medication-related readmissions to 0% with a plan to refer re-admitted elders with high-risk medications for pharmacist consultation pre-discharge.
  • Measuring achievement of project goals through data tracking.

“We are pleased to support health care providers that are working to implement best practices and improve the effectiveness, excellence and efficiency of patient care,” said Shelley Bird, executive vice president of public affairs for Cardinal Health and chairperson of the Cardinal Health Foundation. “We congratulate Our Lady of Lourdes Medical Center and their work to achieve meaningful, long-term improvements.”

About Our Lady of Lourdes Medical Center
Our Lady of Lourdes Medical Center is one of the region’s leading healthcare providers, and has been recognized nationally by HealthGrades® as among America’s Best 100 Hospitals for Overall Cardiac Care. The hospital has also been ranked by US News & World Report as a Best Regional Hospital in the Philadelphia Metropolitan Area and is a Joint Commission Top Performing Hospital.

A regional referral center, Lourdes is a destination hospital for heart care, with one of the largest practices in the Delaware Valley. Specialty clinical services also include: the Lourdes Regional Rehabilitation Center; the Regional Perinatal Center for high-risk mothers and infants; the Lourdes Stroke Center; the Center for Organ Transplantation, the only facility in southern New Jersey performing kidney, liver and pancreas transplants; and the Lourdes Center for Advanced Wound Healing and Hyperbaric Medicine.

About the Cardinal Health Foundation
The Cardinal Health Foundation supports local, national and international programs that improve healthcare quality and build healthy communities. The Cardinal Health Foundation also offers grants to encourage employee service to the community and works through international agencies to donate much-needed medical supplies and funding to those who need them in times of disaster. To learn more, visit cardinalhealth.com/community or http://www.facebook.com/CardinalHealthFoundation.

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Lauren Markin
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