Southwestern Vermont Medical Center and its community partners are receiving national recognition for a new program that helps high-risk patients. It's called the Transitional Care Program. The program uses a specialized nurse to follow high-risk patients—those who are likely to be hospitalized or rehospitalized—through all of the different places they receive care and connects patients to the people and information they need.

A few years ago, several factors contributed to the idea for the program. Our patients had shared that it was difficult and confusing for many of them to navigate their own way through the instructions they receive from the professionals in each of the different areas where they receive care. Second, the hospital was looking for better ways to use the vast knowledge of its most experienced nurses. Third, Village Primary Care in Hoosick Falls, N.Y., was looking for an effective way of fulfilling a Center for Medicare Services comprehensive primary care initiative.

These three factors collided with the knowledge and resources to propose and test a solution. First was the discovery of 20-year-old research from Dr. Mary Naylor at the University of Pennsylvania. The research said that many patients could benefit from one person accompanying them through all of the different places they receive care. The research hypothesized that having a navigator would improve outcomes.

With the support of leadership at SVMC and the cooperation from the Blueprint for Health and Village Primary Care, we assigned three of our most experienced nurses to follow high-risk patents through their care, regardless of the setting: primary care, the emergency room, at the hospital, in the nursing home, and at home.


When a Transitional Care patient requires a hospital stay, the nurse sees the patient at the hospital and guides them through the experience. The nurse follows up with the patient soon after they are discharged — whether they go home, to a rehabilitation center, or to a nursing home. The nurse helps them understand physicians' discharge instructions, provides education on medication, and reviews how to manage their symptoms.

Nurses encourage patients to create realistic goals that they can reach and meet them wherever they are on that journey. The program receives referrals from doctors after an office visit where a patient if found to need help with education or medication management. The nurse connects with the patient in the doctor's office or at their home.

The nurse checks in and communicates with the care providers, too. She ensures that the primary care physician receives updates of what happened in the hospital and the hospital staff receives better background information about the patient's history.

Since its development and subsequent testing, this program has accomplished three unique and very powerful things:

1. It improved care. Patients who would have certainly ended up with multiple hospitalizations have been able to improve their health so dramatically that they don't need to be readmitted as frequently. The latest data compares the experiences of 394 patients 180 days before their first contact with the program and 180 days after. Emergency visits were reduced by 25 percent, and hospital visits went down by more than 66 percent. These patients are living better, healthier lives.

2. It has improved our systems and management. By following patients, we are able to see the gaps in delivery of care like never before. Gaps in care have led to the creation of the Community Care Team, which works to address the unique needs of patients with psychiatric and addiction issues. These patients benefit from "wrap-around" integrated care delivery with multiple community partners meeting monthly. Clinical pharmacists and a community social worker joined the team to address other gaps. We recently implemented a program at the Centers for Living and Rehabilitation that prevents transfers to the emergency department and admissions to the hospital. The program is being shared across all area nursing homes. By doing the hard work of addressing these gaps, we improve care—not just for the individuals in the program—but for all patients.

3. The program has gotten attention from health care organizations nationwide. Because of our success and the program's potential to reduce health care spending, we published our results; we were awarded a Vermont Health Care Innovation Project (VHCIP) grant to expand the program; and I have been invited to speak at conferences in Florida, Arizona and Washington, DC. In September, we will host a regional conference on these topics and their implications in healthcare reform. And in October our Transitional Care Team will be doing a podium presentation in Orlando, FL, as we celebrate our 4th Magnet Recognition for Nursing Excellence. Leaders from much larger organizations are looking at the work being done in our community.

Thanks to support from SVHC leadership, the strength and skill of our partner organizations, and the freedom to innovate, we have the power to change everything. Eventually, this program and others like it are expected to decrease health care spending while improving quality. It's health care reform the way it should be. From right here in Bennington, we are leading the whole country toward a better way of delivering care to high risk patients.

— Billie Lynn Allard, MS, RN, administrative director of care management, transitional care, and ambulatory services at Southwestern Vermont Medical Center.