When Gary left the hospital after a brief stay, he had a lot to remember. Between his old and new medications, new guidelines for managing his high blood pressure, and the effects of his four strokes, Gary could have easily ended up back in the hospital, slowing his recovery even further.
Luckily, Gary had Dinah on his side. Dinah David-Quimen, RN, is a health coach with Sharp’s Community-based Care Transitions Program, part of a countywide pilot program to reduce hospital readmission for Medicare patients. She visited Gary shortly after he returned home to help make sure he knew which medications to take and which to stop taking, and to help him manage upcoming appointments.
“I don’t know what I would have done if you hadn’t come in. I’d have been in bad shape by now,” Gary told Dinah, as they reviewed his case at his dining room table.
Gary is one of more than 7,000 patients served by Community-based Care Transitions, according to program manager Cecile Davis, RN.
“First and foremost, Sharp is interested in patient safety,” she says. “We want to ensure that patients have what they need to continue their recovery from their hospitalization.”
Staffed by 10 registered nurses and three pharmacists, the program reaches out to every eligible Medicare patient discharged from a Sharp hospital within three days to schedule a phone call, home visit or both.
“Our goal is to keep the patient at home as this is where their daily life occurs, where their support lies and where they are most comfortable,” says Davis, noting that coaches are trained to work with patients to help them gain the confidence to manage their own care.
“The plan needs to come from the patient,” she says. “Through the intervention, our coaches assist with the creation of a care plan that involves understanding medications, understanding the patient’s disease process — knowing when to call the doctor and when to call 911 for example. We ensure the patient has a primary care physician and that the patient has an appointment within a week of discharge. Lastly, that all of this comes together in a personal health record which is where all this information is organized for the patient to use.”
While hospital staff can send patients home with some of the tools needed for a successful recovery, some elements lie outside the hospital’s influence. In those cases, coaches can refer patients to community-based services.
“Housing, lack of social support, money for co-pays and medication costs are difficult for hospitals to wrap their arms around,” says Davis. “Sending coaches who understand community support and are connected to programs that give patients support at home is imperative. Our coaching teams are a bridge from hospital to community.”
The Community Care Transitions pilot program has ended. A similar program is now available for patients at Sharp Grossmont Hospital.
This story was updated in June 2017.