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(continued from page 15) and outcomes, not the bottom line.”
you were running a little low,” she said. “One of the big things that
may bring you back to the hospital is falls, so I’m a little worried
that your blood sugar is too low.” The Transitions team isn’t resting on its laurels. Although TICC
has taken huge steps since its inception in 2014, there are still Norton
facilities where it isn’t in place.
It was then off to the medicine cabinet to make sure that Mr.
Brown had all of his medicine stocked and up to date because his
next checkup was still days away. “Our next most likely destination is Norton Women’s and Chil-
dren’s Hospital,” Dr. Person said. “We want to make sure that when
we commit to a new location, we don’t sell any part of the program
short. Every time you start somewhere new, you’re going back to
the beginning. You can’t make assumptions that because one com-
munity embraces it, another one will. This
affects people who are already overworked.
They might be thinking, ‘Oh great, now I
have to do this TICC thing too!’ We know
it’s a two-way street.”
“Until you get back in to see the doctor, I’m going to be your
substitute,” Griffin said. “In the meantime, if there’s something you
need, please call us. We don’t want you to
be without medical care.”
Brown’s wife of 54 years passed away just
a few years prior. Having his daughter avail-
able to help take care of him made a world
of difference and Griffin was happy to say
so. “This is a great situation. His daughter
is so involved, and he’s so sharp. You’d be
surprised how many of our patients don’t
have anyone,” she said.
"They know how to
take their meds, they
know they’re getting
better, and they
feel good about the
process."
Back in the office, the TICC team re-
marked on how proud they were of the per-
sonal care they were able to provide. “We
have our nurses going to do these home visits. There are patients
who cry, saying ‘Oh my gosh, there are people who DO care about
us.’ That experience for these patients, that extra level of care and
support is invaluable,” Lauder said.
The extra care begins each week in the TICC associated facilities.
There, TICC staff members convene to discuss every patient in the
program. “We talk about everything from their hangnail to social
factors,” Lauder explained. “We need to understand the ins and
outs of all our patients.”
Once a patient is registered in the TICC program, they’re regis-
tered for life. “Say my mom goes home and does great, she’s restored
to a level of function. If she gets sick a year later and returns to the
hospital, we can bring in the consult immediately,” Lauder explained.
After two years of positive outcomes at Norton Audubon as well
as buy-in from Norton Healthcare that led to the filled positions of
social worker, additional nurses and late night TICC consultants,
it was time for TICC to go to the next level. Expansion to Norton
Brownsboro Hospital and then to health facilities including Forest
Springs Health Campus, Friendship Health and Rehab, and Sig-
nature Healthcare of East Louisville took place during the second
half of 2017.
“The good news is that we have community partners. The chal-
lenging part is that each of these are very different buildings. There
are hurdles to costs, profit margins, educating staff and available
services. But, once you’re a TICC building, you’re a TICC building
for good,” Dr. Person explained. “You have to have a similar vision
and mission. The commitment has to be towards patient wellbeing
16
LOUISVILLE MEDICINE
As TICC positively impacts patient
health, it also informs the hospitals and staff
about what is and isn’t working. For example,
there are two easily measurable areas which
TICC found needed to be addressed almost
immediately.
“First, we learned that patients are on too
many medicines. Physicians have to work to
reduce the poly-pharmacy. There’s a two or three medicine increase
on average when a person is discharged from the hospital,” Dr.
Person said. “We also learned how the lack of education can affect
care. I don’t care how many times you go over the information; the
patient may go home and take the wrong medication.”
Dr. Person explained that even in a controlled health care en-
vironment, when patients were discharged from hospitals to re-
habilitation centers, it was not uncommon for them to go 15-20
hours without receiving their medications. To alleviate the practice,
medications are now packaged and given to the patient as they leave
the hospital for the next phase of care.
TICC is a work in progress, but it’s already improved patient
outcomes and decreased 30-day hospital readmission rates. By all
measurable accounts, the patient experience is changing for the
better and the health care staff involved feel more rewarded for
their accomplishments.
“It’s reassuring and affirming to extend our reach to the com-
munity at large while also seeking out and supporting our patient’s
individual needs,” said Dr. Person. “It’s too easy to forget that patient
care is a human experience.”
For more information on the Transitions in Care Continu-
um, visit https://nortonhealthcare.com/patient-resources/transi-
tions-in-care-continuum or call 502-639-5150.
Aaron Burch is the communications specialist for the Greater Louisville
Medical Society.