“Improving Care Coordination to Reduce Emergency Room Visits Among High-Risk Patients Through a Nurse-Led Transitional Care Program at Sage Health Over a 6-Week Period”

Project Overview:

This 6-week capstone project will focus on implementing a nurse-led transitional care program at Sage Health Clinic to improve care coordination for high-risk patients, particularly those with chronic conditions (e.g., hypertension, diabetes, COPD, and heart failure). The goal is to reduce unnecessary emergency room (ER) visits by enhancing post-discharge follow-up, medication reconciliation, and patient education.

Project Objectives:

1. Baseline Assessment (Week 1)

• Identify high-risk patients who have had two or more ER visits in the last three months.

• Analyze common reasons for ER visits (e.g., medication mismanagement, lack of follow-up care, uncontrolled chronic conditions).

• Assess current care coordination processes at Sage Health to identify gaps.

2. Intervention Implementation (Weeks 2-5)

• Nurse-Led Post-Discharge Follow-Ups

• Implement 48-hour follow-up calls for high-risk patients recently discharged from the hospital or ER.

• Schedule in-person follow-up visits at Sage Health within 7 days post-discharge.

• Medication Reconciliation & Adherence Support

• Conduct medication reviews during follow-up visits to prevent adverse drug reactions and non-adherence.

• Provide personalized patient education on medication use and potential side effects.

• Chronic Disease Self-Management Education

• Implement weekly nurse-led health coaching sessions on disease management, diet, exercise, and early symptom recognition.

• Telehealth Integration

• Offer telehealth check-ins for patients with mobility limitations or transportation barriers to ensure continuity of care.

3. Evaluation & Outcome Measurement (Week 6)

• Compare pre- and post-intervention ER visit rates among participating patients.

• Assess medication adherence improvements through patient self-reports and clinical documentation.

• Conduct patient satisfaction surveys to evaluate program effectiveness and feasibility.

Expected Outcomes:

• Reduction in ER visits by at least 20-30% among high-risk patients.

• Increased medication adherence and improved chronic disease self-management.

• Higher patient satisfaction with care coordination and access to follow-up care.

Significance of the Project:

• Addresses a common issue in primary care clinics—preventable ER visits due to poor care coordination and chronic disease mismanagement.

• Enhances nurse-led interventions in outpatient settings, reinforcing the role of advanced practice nurses in transitional care.

• Aligns with value-based care models aimed at reducing healthcare costs while improving patient outcomes.