FEATURE
at risk of RTH.
“We sat down and drew the entire plan on a white board. What
would it look like? What patients need support the most? The frail,
the elderly, patients with chronic disease…that’s where the patient
group came from. Patients need to know how to take medication
correctly and what it’s for, how to mitigate falls, etc. It was a process
of figuring out the needs of patients, and creating a protocol so the
criteria developed organically,” said Dr. Person, who also serves as
TICC medical director.
TICC is one of several new programs in the Louisville area
which are currently evolving thanks to the revisionist effects of the
ACA. Many hospital systems in the area have realized a need for
practicing prevention whenever possible.
At Baptist Health Louisville, the Achieving Collaborative Tran-
sitions (ACT) follows a similar path as TICC, providing post-acute
care and supervision for patients most likely to use hospital services
repeatedly. Baptist also collaborated on a heart failure care con-
tinuum with Signature Healthcare. KentuckyOne Health recently
implemented the Health Connections program for residents of
underserved communities. The building of these programs signals
a shift in attitude among the hospital systems. Prevention changes
outcomes.
The petri dish for the TICC program was Norton Audubon
Hospital and two post-acute rehab facilities (Landmark of Louisville
and Franciscan Health Care Center). As a patient prepares to leave
the hospital, they meet with a transitional nurse practitioner (and
in some cases a social worker) to discuss their needs and make
certain the connecting rehab facility is prepared for their arrival.
“Before TICC, we had this mindset that when a patient leaves
the hospital, they’re done. Or, at least they are until we book them
again. If a patient kept coming back to the hospital during residency,
we’d write ‘They are frequent patrons of our service,’” Dr. Person
said incredulously. “So, in beginning the TICC program, we had
to get buy in from all of Norton because there’s so many moving
parts. It’s a culture change for the hospitals.”
One of TICC’s boots on the ground is APRN Becky Griffin.
She guided a GLMS representative through Norton Audubon to
see the TICC program in action. Kneeling by the bedside of an
elderly woman dealing with chronic pain, Griffin explained what
TICC could offer.
“We’re a medical group that goes into the rehab facilities that I
named to you to take care of your medical needs while you’re get-
ting up and going again on your feet,” she spoke softly. “We don’t
want to just dump you there, and for you to not have any medical
care when the doctor isn’t seeing you. When you go home, I’ll see
you there and make sure you have all the medicines you need to
be successful.”
Traveling between hospital rooms, Griffin explained her ap-
proach to each patient she sees. “These patients get 15 brochures at
a time. I know they may not remember TICC. I never try to push
them into it. I just explain the program. Sometimes it’s as simple
as saying, ‘We’re going to give you some extra care there. You may
be more comfortable.’”
Each day for Griffin is different. She may see two patients per
hospital or eight, and the number changes as patients decide if they
want to go to a TICC coordinated rehab facility or not. “The only
consistent part of the work we do with patients is how unpredictable
it is. Every day is different,” she said.
Geoffrey Weiss, Ph.D, TICC Research Grant Coordinator, joined
the team during the pilot to put into words what the staff on the
frontlines is learning.
“The people on the ground always have a good sense of what’s
necessary and what needs to be done,” he said. “So, a grant request
is a good way to structure that and put it in the system.”
Weiss, along with Lauder, Dr. Person and the rest of the team,
drafted a scale with eight dimensions of patient health: general
physical functioning, being able to physically function in a chosen
role, being able to emotionally function in a role, levels of fatigue,
emotional wellbeing, social functioning, pain and general health.
Measuring these eight areas makes TICC able to validate itself
through numbers and evidence.
“The most important thing we learned in the Audubon pilot is
that the program works,” Dr. Weiss said. “Patients were worse off in
just two of the eight dimensions when they left TICC as compared
to when they entered. The two are physical functioning and physi-
cal role functioning. That makes sense that they aren’t functioning
well physically, because they are just leaving the hospital. They’re
recovering from an injury or surgery. So where did they meet or
exceed the baseline? Everywhere else. They know how to take their
meds, they know they’re getting better, and they feel good about
the process.”
Weiss’s words were proven directly on a home visit with Nurse
Griffin. An elderly Mr. James Brown was in the hospital for two
weeks with a UTI, then spent one week at the Franciscan Health
Care Center for rehabilitation. Two days later, Griffin is at his door
introducing herself to his daughter, Jackie.
“This is all brand new to us,” Jackie said. “I’ve taken off work
to be here for him and help him get better. He really wanted to get
back home.”
“That’s everybody’s goal. We want to keep him feeling good and
at home. He’s lucky to have you,” Griffin replied.
Mr. Brown came out from his bedroom looking tired but moving
just fine for an 86-year-old not long out of a three-we ek stint in the
hospital. He was surprised to see a nurse in his home to check on
him, but not ungrateful.
After a quick check of blood pressure, Griffin asked him some
basic questions. “I’m looking back over your blood pressure, and
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