Issue 7 Stories

Forming Bonds, Improving Health

Program Reduces Hospitalizations, Keeps High-Risk Patients Healthy at Home

Carl Foltz has endured multiple hospitalizations for heart failure. At 78, he was living alone and was frustrated about his health and future.

Foltz was admitted to Sentara RMH Medical Center in spring 2017 for shortness of breath and fluid retention. There he met Gina Sprouse, a Sentara community health worker (CHW) who would give him the hope he needed to stay healthy and continue to live independently.

Sprouse told Foltz she could set him up at home with equipment to help monitor his vital signs, as well as help him find some financial relief to ease his burden following discharge from the hospital.

They talked about his grandchildren and how he wanted to be healthy for them. Sprouse’s encouragement was just what he needed, and Foltz hasn’t been admitted to the hospital since then.

“I can’t believe I’ve been able to stay out of the hospital for this long,” says Foltz, of Harrisonburg. “I thought I was going to die. Now I write down my weight, blood pressure and blood sugar every morning. It’s helped me stay out of the hospital.”

Sprouse was able to help Foltz because of the Continuum Case Management program at Sentara RMH, an initiative that has assisted many patients like Foltz in recent years.

Spreading Hope and Good Health

In 2014, Patra Reed, Blue Ridge regional director of integrated care management and Sentara RMH community health, partnered with Sentara RMH’s chief nurse executive, Donna Hahn, to create the Continuum Case Management program at the hospital. Provided to patients at no charge, the program began with three registered nurses (RNs) who focused on patients with heart failure, sepsis and pneumonia. Reed knew that with extra attention and guidance, many of these patients could avoid unnecessary emergency room (ER) visits and readmission to the hospital.

“You can have a beautiful plan set up at discharge, but the reality is different when you step into the patient’s house,” says Reed. “They may not want to tell you that they can’t afford medication. Or maybe they forgot to tell you about pets, a narrow hallway or throw rugs that might get in the way of a walker or oxygen tubing, for instance.”

The Continuum Case Management nurses would meet patients at the hospital and follow up with visits at home. The program’s patient load multiplied, however, and Reed soon discovered that as part of their services they were also handling many nonmedical issues, such as administrative paperwork for disability insurance and prescription coverage.

That’s when Reed introduced to Sentara RMH the idea of the CHW, a position she had learned about from similar programs in other healthcare systems. Well-versed in available community resources, the CHW is paired with an RN in a team-based approach to help patients with medical issues and financial assistance following discharge from the hospital.

With an RMH Foundation grant of $253,000, a pilot program was devised in 2016 to add three CHWs to the continuum care team. Grant funding covered salaries for the CHWs, as well as funds for patient medication assistance and overhead expenses.

Patients must meet specific criteria for referral to the program. They typically will have experienced a lengthy hospital stay and multiple ER visits, and have a complex, chronic disease that requires additional home support. Many patients do demonstrate financial need, but patients are eligible regardless of income. Generally the program follows patients for 90 days after discharge, but that timeline can be adjusted based on future readmissions or other factors.

Working as a Team

When a Continuum Case Management patient returns home from the hospital, his or her assigned nurse works with the patient to develop a care plan, advising the patient on which symptoms to report to the nurse and when a visit to the doctor is recommended. The nurse also often accompanies the patient to doctor appointments.

The CHW assigned to the patient then steps in to address financial needs, helping eligible patients apply for Medicare Part D prescription coverage and other prescription discount programs, Supplemental Nutrition Assistance Program food stamps, and housing vouchers.

According to Reed, the CHW also can schedule doctor appointments, arrange transportation and link patients with community resources, such as Meals on Wheels or various support groups. As well, the CHW and nurses teach patients how to read food labels and create healthier diets by going through their pantries or accompanying them on grocery shopping trips.

Forming Patient Bonds

The trust and respect patients cultivate with their nurses and CHWs are central to the success of the Continuum Case Management program.

“When we visit someone in the hospital, they’re vulnerable because they’ve just had a crisis,” says Laura Watson, RN, a continuum care nurse case manager with the program who specializes in heart failure. “We are patient-centric and want to help our patients successfully manage whatever disease process they might be going through.”

The Continuum Case Management team’s efforts have been shown to have significant impacts on the health of the patients they serve. One morning during a visit, for instance, Sprouse discovered that Foltz had gained four pounds of fluid overnight, so the team called his doctor and requested that his medication be adjusted. This intervention potentially prevented a hospital readmission, solidified Foltz’s trust in his care team and paved the way for them to set up a telehealth machine in his home. The machine monitors blood pressure, pulse and oxygen saturation and transmits the information to the nurse to monitor remotely. Some patients also receive a “talking scale” that sends their weight back to the nurse.

Sprouse also arranged for financial assistance to help Foltz with rent, food, his electric bill and free medication coverage.

“No day is the same, and that’s a great thing,” Sprouse says. “Each patient is in a unique situation, and I have the privilege of figuring out what I can do to help.”

Significant Program Return on Investment

When Reed helped initiate the program, she had a hunch that they could reduce hospital readmissions, ER visits and healthcare costs, all while enhancing quality of life for patients. Since then, she has tracked the program’s outcomes carefully to see if her theory would pan out.

In a study looking at 41 heart failure patients from April-September 2016, Reed found admissions for these patients dropped from 84 before intervention to 17 three months after being a part of the CHW program. Likewise, ER visits fell from 74 to 18. In all, Reed calculated a cost reduction of about $280,000.

A similar study of 114 patients with chronic diseases showed a cost reduction of about $831,000, likewise with fewer admissions and ER visits.

Altogether, the total cost reduction for these 155 patients was approximately $1.1 million—a remarkable return on investment, considering the cost of the pilot program was $342,000.

The pilot program proved to be so successful, in fact, that when RMH Foundation funding ended in December 2017, the hospital agreed to fund the CHW program beginning in January 2018, with the three CHWs as full-time Sentara employees.

Relieving Patient Stress

Charlotte Fertig of Bridgewater was discharged from Sentara RMH in summer 2017 after having cardiothoracic surgery. Her husband was there to care for her, but their expenses were piling up. Even with insurance, her anticoagulant medication alone was $400 per month.

To help relieve some of the financial strain, Sprouse helped Fertig apply for a prescription assistance program that fully covers the medication and sends it right to her door.

“We are truly blessed to have met Laura and Gina,” Fertig says of her nurse and CHW. “They have really helped to take the pressure off us. There’s nothing they wouldn’t do to help you.”

For Kris Bowman, who lives in Philadelphia, the care the program offered her father, after her mother passed away unexpectedly in February 2016, was invaluable. Edward Bowman had been in and out of the hospital since a quadruple bypass in the 1990s. Pat, his wife of nearly 50 years, had been his devoted caretaker.

Kris, a doctoral student and the executive director of an early intervention program for young children, stayed with her father for a couple of months after her mother passed away, setting him up with services that would allow him to live independently in a retirement community.

Those services included linking Edward with the Continuum Case Management program. Kris says her dad looked forward to the days when his caregiving team, Sprouse and Watson, would visit.

“He wanted me to be able to go back to Philadelphia, and I couldn’t have done that without them,” Kris says. “Being almost five hours away, I really appreciated that they cared for him as if he were a part of their family.”

Edward died in September 2016, but Kris continues to stay in touch with Sprouse and Watson, and is still thankful for their efforts.

Expanding the Program

Reed hopes Sentara will expand the Continuum Case Management program to other hospitals and communities, and she has met with Sentara groups throughout the healthcare system to explain the program’s benefits and outcomes.

Reed and her team also have lobbied the state legislature to standardize the education and certification of CHWs, and to standardize reimbursement for their services, as many other states already have done.

She’s proud of what her co-workers have accomplished and the passion they have for the program. The team appreciates being able to play an important role in the successful recovery of their patients.

“These patients receive a diagnosis that’s not going away, and with a little help, you begin to see them taking ownership and starting to manage their health,” Sprouse says. “It’s a beautiful thing to see, and I’m grateful that I’m able to be a part of it.”

RMH Foundation Helps Program for Chronically Ill Grow

When Patra Reed, RN, devised a program to reach more chronically ill patients discharged from Sentara RMH, she turned to the RMH Foundation for help.

Reed, Blue Ridge regional director of integrated care management and Sentara RMH community health, created the Continuum Case Management program in 2014 along with three registered nurses (RNs).

The goal was to decrease patients’ chances of readmission and emergency room (ER) visits by teaching them how to better manage their health at home. The program was very successful, and as nurses began to manage a growing number of patients, Reed realized the program needed extra support.

She presented a new program design to the RMH Foundation, in which a community health worker (CHW) would be paired with each RN and patient.

With a $253,000 grant, the RMH Foundation agreed to fund the pilot program in 2016 and 2017. The grant covered three CHWs, as well as overhead expenses and other patient needs.

“The Foundation has provided funding for assistance with medications, transportation services and other needs that are often unattainable for many of our patients,” Reed says.

Donors, such as Sherry Cline of Harrisonburg, also realize the enormous value the program provides to the community.

“What I really like about this program is that it helps patients eliminate barriers that put their health at risk—especially those with chronic illnesses,” Cline says. “These barriers can cause patients to have recurring visits to the hospital, which is costly to our community. In helping them manage their health needs, we are also helping our community.”

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