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Nurse Intervention Marks 5 Years of Smoothing Transitions of Care

Nurse Intervention Marks 5 Years of Smoothing Transitions of Care

Johns Hopkins Health System hospitals care for patients who often have complex medical conditions or challenges related to social determi­nants of health. When these patients are discharged, how well they manage their care at home can make the difference between a smooth recovery or a return to the hospital.

One program the health system has initiated to provide support during this critical transition is the Patient Access Line (PAL), which marks its fifth anni­versary this month. With PAL, patients going home without other services receive a call from an experienced nurse case manager to see how they are doing and ensure they understand their care plans. Launched under a Center for Medicare & Medicaid Innovation grant, PAL was designed to provide the follow-up needed to improve care and reduce the costs associated with potentially avoidable utilization.

Melissa Richardson, interim vice president for care coordination for the Johns Hopkins Health System, says the calls also represent an opportunity for the PAL case managers to offer comfort, provide additional teaching and review important details such as medication regimens and doctors’ appointments. “We want to know things like, ‘How are you feeling? Same, better or worse?’ If it’s worse, we’re going to dig into that and engage the appropriate follow-up— whether suggesting a call to the doctor, a visit by a transition guide or a trip to the ED.”

Over the years, PAL has expanded from a staff of four to 11 nurses and now serves patients from The Johns Hopkins Hospital, Johns Hopkins Bayview Medi­cal Center and Howard County General Hospital. In total, the service has con­nected with more than 41,700 patients since 2013.

The impact is positive. Data show that in a 40-month period between January 2014 and April 2017, there was a 29 per­cent relative reduction in the readmission rate for the nearly 38,300 patients who received PAL calls. Those who did not get connected with PAL—usually be­cause no one answered the phone or the line was disconnected—had 45 percent increased odds of readmission compared with those who did. During this interval, PAL prevented 777 readmissions, result­ing in $11.8 million in cost savings.

PAL Manager Susan Wolfe praises the training, dedication and persistence of her staff members and other provid­ers who go the extra mile to ensure all patients get safe, quality care.

She points to a Howard County General Hospital physician who made a home visit to check on a patient with a concerning cough and whose caregivers were out of town; the intervention for an elderly Johns Hopkins Hospital patient who was in respiratory distress but hesitant to call 911; and the persistence to reach a Johns Hopkins Bayview Medical Center patient whose phone number was disconnected and who was later found to need emergency services. (See sidebar.)

With the PAL call, nurses are able to sense fear and anxiety, identify medi­cal issues such as shortness of breath or uncontrolled pain, and expertly assess a patients’ ability to care for themselves. “I’m proud that they connect with the patients with the intention of making a difference,” Wolfe says.

Richardson agrees: “There is very, very strong desire within that group to make sure that the patient is ‘tucked in’ after they’ve left the hospital or ED.”


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