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Care-CO-ordination and eMpowerment of Patients in Systems-to-Systems Transitions (COMPASS program): Implementation and Outcomes of Transitions of Management of Care Using a Client-Centered and Fiscally Responsible Approach

Description of project: Evidence-based quality improvement practice program demonstrating that implementation of a transitional care management (TCM) program during the early post-hospital period and extending through the care phases and into the discharge process to home or community settings will lead to important improvements in resource utilization, patient satisfaction, and post-hospital outcomes including rehospitalization.

In system-to-system transitions, patient and caregiver education and empowerment facilitate high-quality discharge communication to ensure that the nursing home is ready to implement a post-hospital care plan. Often, high-quality discharge communication during system-to-system transitions does not occur.

The COMPASS program can fill this gap, supporting patients discharged to nursing homes and then the community (when appropriate) by incorporating patient and caregiver education empowerment while ensuring high quality, bi-directional system-to-system communication between the hospital and next care setting.

We developed a nurse practitioner led program at VA Pittsburgh Healthcare System (VAPHS) for complex veterans being discharged from our primary referral hospital to community living center (CLC, i.e., nursing home equivalent) and eventually to home. To accomplish this, we developed two distinct teams: The COMPASS admission team (CAT) and the COMPASS discharge team (CDT). The CAT assesses medically complex CLC-eligible veterans in the acute care facility, whereas the CDT manages veterans in the CLC and assists with their and placement in the community.

Method: Evidence-based quality improvement practice program.

Data analysis: Designed encrypted spreadsheet obtaining data measuring number of veterans seen, Medication reconciliation errors detected and hospital readmissions. Data obtained is unit-based metrics and workflow statistics standardize to improve care processes and ultimately patient outcomes.

Few outcome results
1. 10/2021: Number of COMPASS (hospital to CLC) veterans served cumulative: 173
2.    2/2022: Number of COMPASS (hospital to CLC) veterans served cumulative: 253
3.    Demonstrated that a focus of transitional care coordination can have the potential to reduce the 30-day readmission rates.
4.    4. Medication reconciliation error 207: An advanced practice nurse practitioner-led model can demonstrate that system-to-system transitions of care can be integrated into a large complex healthcare system to produce organizational, operational, and veteran impact. More research is needed along with comparative data to show the precise value of this program.