From Hospital to Healthy: Transitioning Patients So They Stay at Home

The Visiting Nurse Association of South Central Connecticut is helping patients manage their own health, so they don't end up in the hospital again.

With support from a Community Foundation multi-year grant, the Visiting Nurse Association of South Central Connecticut has been working to reduce the re-hospitalization rate of patients discharged from Yale New-Haven Hospital.

With the help of Transition Coaches, nurses that work with patients before their discharge from the hospital, check on them at home and ensure that patients get to their follow-up appointments with doctors, VNA South Central has documented a 20% decrease in the rate of re-hospitalization among those patients in the program.

"Patients kept their own personal health record to record how they felt daily, keep track of doctor appointments…they still use these today," said Carla Giugno RN, BSN, Vice President, Clinical Services & Agency Administrator at VNA South Central. "The readmission rate for our clients under this program was 5.9%, versus the national benchmarks of 28%."

One patient, diagnosed with congestive heart failure, was afraid to be sent home alone. After visits with his Transition Coach, he became more comfortable with the medications and personal health record and decided he would not let his diagnosis control his life. He followed up with his cardiologist regularly and had not been re-hospitalized when VNA South Central last reported on the program.

"The Visiting Nurse Association of South Central Connecticut would not have been able to even start the program without funding from The Community Foundation," said Giugno.

Just announced this week, the VNA South Central will take on the services and home care to the residents of the Borough of Naugatuck who have been receiving care from the municipally-run Naugatuck Visiting Nurse Association. The Naugatuck VNA will be closed as of September 30th.

Funding for this program was made possible by the Jennie C. Bronson Fund at The Community Foundation. Learn more about VNA South Central at

Did You Know?

Re-hospitalization, or "readmission", refers to a patient being hospitalized within a certain time period from the initial admission. Under Medicare, readmission is defined as a patient being hospitalized within 30 days of his or her initial hospital stay.

Source: "Medicare Hospital Readmissions Reduction Program"