Patients who lack health insurance and a healthcare provider may not know of anywhere else to turn but to the emergency room for treatment, support, or medication.
Iredell Health System’s Care Transitions department connects these patients, often struggling with mental health or addiction, with providers and community resources, helping them understand how to care for themselves at home and preventing them from being readmitted to the hospital.
“The whole focus of the program is to make sure the patient’s needs are met even after they’re discharged home,” said Care Transitions Coordinator Judy Porter. “Our job as a healthcare institution does not stop when they walk out that door.”
Porter earned a bachelor’s degree in social work from Ohio State University before earning a master’s degree in counseling from Cleveland State University. She has spent many years, and most of her career, working in healthcare social work, and has been with the Iredell Care Transitions Clinic for five years.
The care transitions team has traditionally served patients with one of five high-risk diagnoses: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia, total joint replacements, or myocardial infarction (MI). Last year, COVID-19 was added to that list.
After being home a few days, some patients realize that managing their health was a harder task than they had realized. Care transitions coordinators will connect those patients with a home health agency, following up to make sure the agency has contacted them.
Able to troubleshoot situations on their behalf, Iredell Care Transitions encourages patients to let them know if things aren’t going well.
Iredell Care Transitions coordinators determine the safety of the patient’s housing situation. They make sure the patient has scheduled doctor’s appointments along with transportation to the appointments. They educate patients on the disease process, talk to them about their diet, and encourage them to set goals. They may talk to patients struggling to eat about local food pantries, and their assessments help them identify substance abuse issues to discuss with the patient and connect them with a related program.
“A day doesn’t go by that we don’t have a feeling that we’ve accomplished something, hearing those people giving you feedback,” said Care Transitions Coordinator Theresa Graham. “There are people for whom it is just routine. But for those ones that we really touch, they’re taking pride in the fact that they got this education and now they’re going to use it.”
Graham earned a bachelor’s degree in healthcare management from Gardner Webb University. She has worked for Iredell Health System for 11 years and has been with Iredell Care Transitions for a year.
“This is where my heart is,” Graham said. “You can go home and be proud of the outcome. For some patients, you don’t have to ask questions because they’re just so excited to tell you. And that makes your day.”
For its CHF patients, the team provides literature, reviews their diet emphasizing sodium intake, makes sure they’re completing daily weigh-ins, and helps them understand when to call their doctor because of fluid gain. The care transition coordinators ensure patients have their medical equipment delivered and working properly, contacting medical equipment companies if necessary.
“A lot of our patients aren’t taken seriously. They need somebody like this clinic to say, ‘We care about your health. We want you to improve. We want you to be connected,’” Porter said.
After performing a risk assessment on each patient, Iredell Memorial Hospital case managers send referrals of high-risk patients to the care transitions team. Before the COVID-19 pandemic, the care transitions coordinators performed initial visits with the patients in their homes, completing the assessment process with them in-person. Now, they are forced to meet over the phone, which has affected their care.
While Iredell Care Transitions coordinators address the social and emotional needs of patients, Nurse Practitioner Katie Kissel provides them with medical care. The team may connect patients with a mental health agency or Iredell Health System’s psychiatrist, Dr. Mona Ismail. Ismail joined the Iredell Psychiatry practice in August 2020.
“We do whatever we can to make sure that their focus is on their health and setting goals to try to better their health. Now that we have a psychiatrist, we’re thrilled,” Porter said.
The care transitions team’s patients take advantage of community resources and ongoing healthcare providers they weren’t aware of before, no longer considering the emergency room to be their easiest healthcare solution. They also receive help with getting needed medications, including several which are free of charge.
Iredell Care Transitions coordinators collaborate closely with other Iredell Health System departments, such as referring patients to the Iredell Wound Care & Hyperbaric Center, or the Cardiopulmonary Rehabilitation programs. When they are introduced to a newly diagnosed diabetic patient struggling with concepts, they invite Diabetes Educator Mandy Brawley to help provide valuable education.
When hospital patients receive education along with their care, they may feel bombarded with new information. During weekly calls with patients, Porter and Graham make sure patients understand their diagnosis and disease process along with the importance of ongoing healthcare.
“With these week-to-week calls, we get to know the patients and gain an understanding of if they are really working toward their goals or are just going through the motions. Then we try different ways to plant that seed,” Porter said. “They may not accept it right now, but a month or two down the road, they may say, ‘Oh my goodness, this is what I need.’”
After undergoing a surgery at Iredell Memorial, one high-risk patient received homecare from Iredell Home Health, as well as wound care from the wound care center. The care transitions team could tell he was frightened with his circumstances the first time they met. But throughout his treatment, the team operated as a support system for him, making sure he knew he was not alone.
The care transitions coordinators lose some patients along the way, and some don’t respond to calls. But they turn no one away. Some return to their office more than a year after their discharge remembering it as a place where they were listened to and where people cared.
“We are cheerleaders in the background cheering them on,” Graham said. “It is very fulfilling and rewarding.”
Pictured — The Care Transitions team, from left to right: Judy Porter, Katie Kissel, Theresa Graham, Renee Young