HAP Resource Center

Case Study: Doylestown Hospital 2019 HAP Achievement Award

HAP Achievement Awards Logo

Awarded for: Cardiothoracic Transitional Care NurseCaregiver helping patient at home
Excellence in Care
Medium Organizations

The goal:  Improve patient satisfaction and outcomes after heart surgery while reducing avoidable readmissions and transfers to skilled nursing or visiting nurse agencies.

Doylestown piloted the use of an on-staff cardiothoracic transitional care nurse and now has two such nurses who:

  • Round with cardiovascular surgeons to follow patients’ progress and collaborate with the hospital care team
  • Can set up as many visits as needed—usually two or three, but sometimes many more—to address patients’ needs at home post-charge and support a smooth recovery
  • Act as liaisons between patients and physicians—patients can call with any questions, and talk with their transitional care nurses, who have deep understanding of their patients as well as patients’ surgeries and providers

Patients’ health plans are not charged for these visits, which are considered part of the surgeon’s services.

Results:  Patient satisfaction increased dramatically, with the readmission rate dropping to 9–12 percent, will below national averages. What’s more, the transitional care program resulted in savings for the health system.



Topics: Public Health, Quality Initiatives

Revision Date: 9/1/2019

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