Blessing Hospital pilots transitional care program to keep patients from returning to hospital

Posted: Nov. 24, 2012 7:37 pm Updated: Dec. 15, 2012 11:15 pm

Herald-Whig Staff Writer

Blessing Hospital hopes a new program reduces the number of patients.

A new transitional care program aids patients at high risk for readmission to the hospital. Dena Nokes, a Blessing Care manager, makes in-home visits to patients who may struggle with their conditions after they have bee released from the hospital. She ensures they understand when to take medications and monitors clients' medical maintenance. That allows Nokes to handle client issues or seek answers from other agencies without patients being readmitted to the hospital.

"It just depends on the diagnosis actually," Nokes said. "It's making sure they know what they're taking, why they're taking them and have a regiment for them."

Blessing Health System has implemented care coordination services to help residents navigate local health care services. This service, formerly known as the Access Health department, provides service navigation, chronic disease management and transitional care management. When appropriate, the program also provides access to mental health services.

Julie Shepard, administrative coordinator for the Care Coordination, said the program helps patients until their next doctor visit.

"It's just designed to help them fill in the gaps until they get back in," Shepard said. "It helps them prepare for that (next) doctor visit."

Once a patient is identified as a high risk for readmission, a nurse care manager or caseworkers will arrange home visits and make telephone calls to address medication management, primary care provider appointment attendance and potential warning signs of a condition worsening.

"To improve a person's health it has to go beyond the walls of the hospital," Shepard said.

Shepard hopes this program empowers patients to become more knowledgeable about their own conditions. Nokes said teaching patients the proper questions to ask their doctors reduces the risk for extra time in the hospital.

"It's kind of empowering to have them to take more control of their health," Nokes said.

Recently, Nokes helped a client replace a broken scale. The patient needed to monitor her weight and liquid intake, and Nokes discovered the scale she had been using wasn't working properly. The in-house visit helped the patient realize that she hadn't been properly recording her weight and may have prevented a future in-patient stay at Blessing Hospital.

"It's designed to be an intervention until they get back to their primary care," Shepard said.

The program's service navigation assists clients in connecting to health care services or in meeting social service needs. Shepard said often patients don't know what resources they qualify for and how to pursue obtaining those resources. Clients may seek assistance with community resources, coordination of health care services and assistance with applications for available programs.

"We have a lot of great resources in the community and a lot of people don't know they're eligible," Shepard said. "They get frustrated, and they don't know what to do next."

Providing access to these other agencies helps patient bridge the gap until their next doctor visit, limiting unnecessary hospital stays.

"Nobody wants to be hospitalized or receive more medical care than they need," Shepard said.