Groups

Indiana University Bloomington senior nursing and second year medical students work with the Indiana University Health Bloomington Transitional Care Nurse manager to conduct home visits to patients discharged from acute care who are high risk for readmission.

Interprofessional student teams use a patient-centered approach where they:

• Perform a focused history and physical assessment
• Reconcile medications
• Evaluate patient ability to manage self-monitoring
• Estimate nutritional needs
• Scan the environment for risks
• Assess for equipment needs
• Screen for telehealth monitoring

Year 1 data indicates that patients in the program experienced a:

• Reduction in 30-day readmissions from 36% to 0%
• Reduction in any readmissions from 64% to 28%
• Increased average day to readmission from 72.88 to 98.29 days

https://nexusipe.org/advancing/nexus-innovations-network/indiana-university-bloomington-nexus-project

Contacts:

Deanna Reising          dreising@indiana.edu

Derrick Garletts          dmgarletts@indiana.edu

Kara Bierbaum            kbierbaum@iuhealth.org

Doug Carr                   decarr@indiana.edu