|Staffing the new patient-focused initiatives on health care transitions are (standing) Kelly Rierson, BSW, medical social worker, FirstHealth Home Care and FirstNavistar; and Teresa Hunsucker, R.N., guided care nurse, FirstHealth Home Care and FirstHealth Montgomery Memorial Hospital; and (seated) Lynn Lanier Agee, R.N., BSN, care navigation nurse, FirstNavistar.|
PINEHURST – Health care transitions, or moving from one level of care to the next, are vulnerable times for patients and their caregivers. Transition challenges such as ineffective communication, medication errors, lack of physician follow-up and poor coordination of services often lead to re-hospitalization and reduced quality of life.
These challenges can be even more complex for patients with chronic diseases.
According to the Centers for Medicare and Medicaid Services (CMS), 80 percent of Medicare re-admissions are avoidable. Studies also show that 50 percent of patients don’t see a physician before a 30-day readmission and 60 percent of patients leave the hospital with no knowledge of the post acute care services that are available to them.
Armed with this knowledge, FirstHealth Home Care has launched patient-focused initiatives to address health care transitions and reduce hospitalization while improving quality of life for patients with chronic illnesses.
Montgomery County’s Community Care Coordination Program (MC3) is a grant-funded program designed to ease transitions and coordinate care across the continuum for Montgomery County patients with chronic conditions such as congestive heart failure, COPD, hypertension and diabetes.
A Home Health-guided care nurse, positioned within FirstHealth Montgomery Memorial Hospital’s Emergency Department, can address patients’ immediate needs upon discharge and help arrange the appropriate community resources.
The guided care nurse also works closely with partners from Community Care of the Sandhills to improve access to care for patients with chronic disease.
FirstNavistar is a call center staffed by a guided care nurse and social worker who provide care navigation for referrals and information on community, health and medical resources in Moore, Montgomery, Hoke, Scotland, Richmond and Lee counties. Funded by the Foundation of FirstHealth, phase I of FirstNavistar begins with assistance to all FirstHealth Family Care Centers. Phase II will expand access to area physician offices, and Phase III will open FirstNavistar to the public.
The basis of FirstNavistar is a robust and comprehensive database of area resources. When Phase III opens the program to the public, a website will be introduced to give patients and caregivers extensive information on physicians, support groups, events and available services in addition to the professional assistance of the care navigators.
For easy public access, the entire program will be housed in the new Clara McLean House at FirstHealth, a hospitality house on the campus of FirstHealth Moore Regional Hospital.
“These transitions of care initiatives are consistent with the overall strategy to improve the coordination of care across the health care system,” says Patty Upham, director of FirstHealth Home Care Services. “This dynamic approach to the management of chronic disease has an overarching goal of reducing hospitalizations and emergent care, improving self-management skills and improving the quality of life for our patients.”
FirstHealth Home Care (FHHC) is made up of two licensed home health agencies with offices in Rockingham and Taylortown. FHHC cares for patients in Moore, Richmond, Montgomery, Hoke, Scotland and Lee counties. The 40 nurses and physical therapists travel more than 600,000 miles a year and maintain an average daily census of 400 patients.
Home health provides skilled care on an intermittent basis to homebound patients who are under a physician’s care. Its skilled services include infusion therapy, advanced wound care, diabetic teaching, post-operative care, disease-specific education and self-management, rehabilitation services, falls prevention and medication management.
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