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New roles nurses serving chronically ill patients

Southwestern Vermont Medical Center (SVMC) embarked on their Transitional Care journey in 2013 by redeploying and preparing acute care Clinical Nurse Specialists from the ICU, ED and Telemetry units.

SVMC has partnered with all primary care practices in their service area, navigating with chronic care patients from one setting to another, working closely with the medical home, skilled nursing facilities, homecare partners and community agencies. In the past 2 years, their TCM program has expanded to include clinical pharmacists, social workers, certified diabetes educators, respiratory therapists, health promotion advocates stationed in the ED, and a leading Community Care Team (behavioral health and addiction) and Interact educator (skilled nursing facilities).

“Our Chief Nursing Officer supported us to do a pilot program with an investment of hospital resources based on declining inpatient volume jeopardizing appropriate use of Clinical Nurse Specialists. When we were able to demonstrate a consistent 68% decrease in hospital admissions for our patients, we were able to convince the CFO and CEO that this was an important part of transforming healthcare delivery and meeting the triple aim.” 

Expert clinical nurse specialists–now Transitional Care Nurses, navigate with patients from one setting to another are able to clearly identify gaps in care, coordination, communication and opportunities for improvement. On the horizon for SVMC is an expansion to include maternal newborn patients with addiction/mental illness, community dietician and physical/occupational therapist (ED and community). In SVMCs community, it is clear more resources are needed to address socio-economic issues interfering with creating a healthy community, and “we are leading an accountable community of health project working closely with community partners.”