Hospitals today are leaders in the development and delivery of care to patients.
Two programs recently introduced Franciscan Alliance programs that address these specific issues are already showing great promise.
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.
“Two main focuses of nurses’ home visits include continuing medication training and sorting through all medications in the patient’s home,” Clemons added.
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.
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.
Medical Specialists, led by president Alexander Stemer, M.D. who initiated the program concept 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.”
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.”
President of Franciscan St. Margaret Health Tom Gryzbek said the 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.”