Tallahassee Memorial Hospital

Tallahassee Memorial Hospital’s Transition Center Helps Patients Access Needed Follow-Up Care, Improving Overall Health and Saving Patients Money

Tallahassee, Florida

Independent Not-for-Profit Hospital

772 Beds

Tallahassee Memorial HealthCare, Capital Health Plan and the Florida State University College of Medicine are collaborating on the Transition Center, an innovative new facility that opened in February 2011 to provide follow-up care to patients discharged from Tallahassee Memorial Hospital (TMH) who are at risk for readmission. Patients seen at the Transition Center include adults who were hospitalized at TMH and meet any of the following criteria when they are discharged:

  • Patients without a primary care provider.
  • Patients without health insurance.
  • Patients who are not able to obtain a follow-up appointment with a physician within seven days of discharge
  • Patients who have been hospitalized three or more times over the last 12 months

Patients may be seen at the Transition Center for a variety of reasons.   It is a place where high risk patients can receive care once they have transitioned out of the hospital.  The patient’s social and psychological needs are evaluated as well as their physical needs. The main focus is to provide the patient with the opportunity to improve his or her health status through education and support, and through providing medications or any services that they may otherwise not be able to afford or access. This increased access and continuity of care can reduce hospital readmissions, which not only improves quality of life for patients, but is also projected by the Centers for Medicare and Medicaid Services to dramatically reduce the overall cost of health care.

TMH Chief Medical Officer Dean Watson, MD, developed the original idea for the Center. He explains, “In essence, we want to be available to provide care for patients who can’t see their physician within five to seven days of discharge from the hospital and are at high risk for readmission. We want to make sure they get the care and support they need through a multi-disciplinary approach to prevent them from having to come back to the hospital.”

One unique aspect of the Transition Center is the role of the RN Care Coach. The Coach calls patients after discharge from the hospital and in between appointment visits to educate patients on their disease and encourage patients to support their role in self-management.  “Establishing a place where discharged hospital patients can receive care was the focal point of phase one of this facility,” stresses Dr. Watson. “Phase one was a creative collaborative effort of the hospital and community.”

The successful collaboration and completion of phase one has allowed for the initiation of phase two, which includes research, chronic disease management, telehealth expansion and multi-disciplinary learning opportunities. “Phase two of the Center involves expanding care for patients with chronic diseases, such as heart failure, COPD and diabetes at the Transition Center and other locations through remote telecommunication systems as well as further developing the educational component of the program,” Dr. Watson explains.

The Center currently provides a multi-disciplinary learning environment, bringing together the Tallahassee Memorial Family Medicine Residency Program, the Florida State University (FSU) College of Medicine, College of Social Work and College of Nursing, the Florida Agricultural and Mechanical University (FAMU) College of Pharmacy, and Tallahassee Community College’s Respiratory Therapy and Medical Technology Programs and will continue to expand these opportunities.

According to Dr. Watson, “We have the best of both worlds.  Nursing, medical, pharmacy and allied health professional students learning and caring for patients together, under the guidance of amazing medical personnel, all while providing care for a high-risk patient population—a multi-disciplinary approach to education with a focus on patient-centered care.”

Since opening in February 2011, the Center has treated over 1,000 patients.  In 2012, inpatient charges for Transition Center patients were reduced by 58 percent.  Although the Transition Center saved the hospital money, the more important fact is that the patients utilizing the Transition Center received timely and much needed care. In 2012, emergency room visits for Transition Center patients were reduced by 35 percent, and total inpatient days were reduced by 61 percent.