Hospitals today are leaders in the development and delivery of care to patients.
“While there is much variation in the size and scope of hospitals, all hospitals have the opportunity to lead in the improvement of health care delivery so that the right care is delivered in the right place at the right time for every patient,” a recent report by the Joint Commission on the Guiding Principles for the Development of the Hospital of the Future states. “The rise in the number of patients who are aged and those who are chronically ill, challenge hospitals to extend the parameters of hospital-based care from inside the medical center, to the community and into the home.”
Two programs recently introduced Franciscan Alliance programs that address these specific issues are already showing great promise.
Now, chronically ill and elderly patients who have been discharged from the hospital stand a better chance of being able to remain in the comfort of their homes and avoid readmission.
With the goal of keeping patients at home, sweet home, Franciscan Home Care Services in Crown Point, in collaboration with Franciscan Alliance Northern Indiana Region hospitals, recently established the Franciscan Alliance Care Transitions Program.
This unique collaboration between social workers, case managers, physicians, nurse navigators and discharge planners identifies patients 18 years of age or older who may be at high risk for readmission within 30 days of being released from the hospital.
Then, through the Care Transitions Program, these patients receive education and discharge planning while still hospitalized, with home follow-up visits scheduled and coordinated by specially trained nurses.
The current focus is on patients who have had cardiovascular issues, pneumonia and diabetes.
“The program is focused on optimizing patient health at and after discharge, empowering patients and their families to be active, educated participants in their health care outcomes,” Rose Clemons, Franciscan Alliance regional director of case management, said.
With more than 600 clients already, the Care Transitions Program is in place at Franciscan St. Anthony Health-Crown Point, Franciscan St. Anthony Health-Michigan City and Franciscan St. Margaret Health-Dyer and Hammond.
“Two main focuses of nurses’ home visits include continuing medication training and sorting through all medications in the patient’s home,” Clemons added. “A patient often will have a dozen medications in the kitchen drawer, in addition to the ones they received upon discharge. These could be different doses of the same medication or medications that should not be taken together.”
Franciscan Home Care Services registered nurses Rose Veteto and Kyle Cruz help patients sort through all of them and provide a system for taking the correct medications, while placing the others elsewhere to avoid mix-ups.
“Before discharge, the patient or caregiver is introduced to a personal health record tool that enables them to record questions and information regarding self-care concerns, have a medical history list, a ‘red-flags’ list that includes symptoms of worsening conditions, and a listing of physicians, pharmacies, equipment companies and other information that should be shared with health care providers,” Veteto explained. “The nurse also encourages the patient to list goals he or she wants to accomplish over 30 to 60 days.”
Then during the home visit, the nurse reviews all of this with the patient-caregiver – from the health record, goals and medication information to “red-flag” signs, stressing the need for making prescribed follow-up physician visits while discussing knowledge of the patient’s disease process and what he or she is doing to self-manage. Follow-up phone calls are also scheduled for after the visit.
“If a patient or caregiver identifies a health concern on their own, they are instructed to contact their doctor, depending on the concern,” Veteto said. “To date, we have had a less than 10 percent readmission rate to acute care facilities, and a recent survey for the first quarter of this year indicated a 90 percent satisfaction rate.”
Further addressing the specific needs of seniors in our communities, Franciscan Alliance is also now reaching out to nursing homes.
By extending its hand of care beyond hospital and clinic walls, Franciscan Alliance is helping to keep geriatric residents healthier with better treatment and ultimately shortening the stays of those who require hospital admission.
Together, Franciscan Medical Specialists, which began sending “snificists” (skilled nursing facility physicians) and nurse practitioners to nursing homes in the 1990s, and Franciscan Alliance’s five hospital campuses in Crown Point, Michigan City, Hammond-Dyer and Munster offer the program in approximately 10 area extended-care locations.
Medical Specialists, led by president Alexander Stemer, M.D. who initiated the snificist program locally, joined Franciscan Alliance last year.
“It creates a win-win-win situation for patients, nursing homes and hospitals, since their missions align,” he explained. “This is an example of a health care institution recognizing the evolving demands of an aging population and trying to provide the best possible services to the community.”
Stemer, who recognized the need for such a program in the area years ago after receiving medical training in an advanced geriatric center in Chicago in the 70s, described how physicians and nurse practitioners who regularly visit these facilities provide residents consistent, high-quality care.
“The care in nursing homes must equal the quality of care patients receive in hospitals,” he said. “Physicians who round in nursing facilities work with hospitalists (hospital-based doctors) and specialists so information is more effectively shared. Nursing home patients are being seen by physicians who specialize in care to the elderly.”
Claude Foreit, D.O., president of Franciscan Physician Network for St. Margaret Health Dyer-Hammond, said the program’s nurse practitioners also enhance the level of supervision and patient care, since they visit the homes most often.
“We have received positive feedback (about this program),” he said. “Our hospitalists are more comfortable transferring patients to the skilled nursing facilities we serve. They know the nurse practitioners and have met the doctors.”
Stemer further pointed out that nursing home standards of care increase along with the individualized attention residents receive.
“As the older population continues to rise, so does the need for high-quality extended-care services for those who find they are not able to stay alone,” he said. “Our advanced elderly patients constitute one of the fastest-growing segments of our population.”
President of Franciscan St. Margaret Health Tom Gryzbek said the snificist idea is consistent with the mission of the Sisters of St. Francis of Perpetual Adoration, founders of Franciscan Alliance.
“Our ministry works to identify the needs of the communities we serve. In that sense, we try to find unmet needs in the health care delivery system and create answers to those challenges. We are embracing that with our growing, aging population.”
For Your Info:
Franciscan Alliance Transitional Care Program
Franciscan Home Care Services
219.661.5300 or 219.877.1605
Franciscan Alliance Senior Services - Snificists Program
Franciscan Medical Specialists
A comprehensive network of 11 primary and specialty care offices
Franciscan St. Anthony Health – Crown Point
1201 South Main Street
Franciscan St. Anthony Health – Michigan City
301 West Homer Street
Franciscan St. Margaret Health – Dyer
24 Joliet Street
219.865.2141 or 708.895.1650
Franciscan St. Margaret Health – Hammond
5454 Hohman Avenue
219.932.2300 or 707.891.9305
Franciscan Healthcare – Munster
701 Superior Avenue