USF-UF Team Devises Specialty Transitional Care Program to Improve Patient Services

Shayna Rabess

Gator, Shayna Rabess, and Bull, Gisela Kennedy, land finalist spot in the 2020 Florida Blue Health Innovation Challenge with a project that would improve the care transition from hospital to home to the healthcare provider by implementing transitional care management (TCM) services. The innovation is aiming to decrease the time from hospital discharge to healthcare provider visits.

The team proposes the implementation of a Specialty Transitional Care Program for patients transitioning from hospital to home, who have conditions that are high risk for readmissions, such as congestive heart failure, myocardial infarction, chronic obstructive pulmonary disease, pneumonia, sepsis, or who are at high risk for poor outcomes. 

Their innovation would support a reduction in unnecessary hospital readmissions through improved patient outcomes, better access to care, and proactive care management. The team’s research found that when patients are discharged from a hospital stay, regardless of risk for readmission, they could experience delays of seven to 14 days before seeing a primary care provider. The delays are even longer when it comes to seeing a specialist.

“For a hospital to impact readmission rates and subsequent associated non-billable costs, it will need to implement care coordination from discharge to healthcare provider visit for high risk of readmission patient populations,” said Rabess.

The Specialty Transitional Care is an innovation that is not intended to replace patient non-facility healthcare providers, but rather to bridge the gap and improve the coordination of transitional care for high-risk populations across the healthcare continuum.

The duo wants to improve access to care since access is the main challenge that patients face when they end up visiting an emergency department and ultimately being readmitted either for a previous concern or a different concern.

“Primary Care is invested in this model with dedicated follow-up and communication, but specialty care lacks the collaboration from other entities, like a social worker, nurse, scheduling staff, etc.,” said Kennedy.

Rabess has been a nurse for 10 years, working primarily in cardiology. She is currently working on her doctor of nursing practice degree, where her research has focused on improving care transition from hospital to home to the healthcare provider in the heart failure population by implementing TCM services which include 72-hour post-discharge telephone contact, and a follow-up visit within seven to 14 days of discharge. 

“TCM services are generally underutilized including in my current clinical practice,” said Rabess. “Using what I know from the ambulatory side and the inpatient side has shed light on some of the gaps in healthcare, especially as patients’ transition between hospital settings.”

Kennedy’s biggest motivation comes from veterans and specialty healthcare providers. She works at the Bay Pines VA Healthcare System’s Department of Medicine as an administrative officer, where she provides supervision of 11 direct reports and leads operations for over 175 clinical providers in 12 specialties. From 2003 to 2007, Kennedy served in various roles as a United States Army Logistics Officer in Virginia, Hawaii, and Kandahar, Afghanistan.

“I listen to my providers every day telling me how grateful they are to work in a hospital where they are confident their patient will get the medication they are prescribing because the pharmacy automatically sends it to them or how they can contact the scheduling team to facilitate an appointment for a patient just to make sure they are ok,” said Kennedy. “This spirit of the good that we can do is what inspired this project.”

Their project will support both access to care from the patient perspective and easy processes from the provider perspective. The team presented in front of an esteemed panel of expert judges during the 2020 Florida Blue Health Innovation Challenge finals.