Debbie Wilmot, left and Barbara Nay are transition coaches in the Hospital-to-Home program in the InterCommunity Health Network Coordinated Care Organization.
June 4, 2013, (Albany) — The InterCommunity Health Network wants to help Oregon Health Plan members avoid unnecessary trips to the emergency department. The coordinated care organization serving Linn, Benton and Lincoln counties has launched a "Hospital-to-Home" initiative at Samaritan Albany General Hospital to reach out to people with certain chronic conditions who are at a higher risk of being readmitted within 30 days of leaving the hospital.
"We focus on the patient. We help them manage their own conditions to keep them from being readmitted and also to improve their health," says project lead Gale Blasquez. Blazquez is a program manager with Senior and Disability Services for the Oregon Cascades West Council of Governments, which is guiding the program for the CCO.
"We work with patients to set up their own health goals and we help them reach those goals." ~ Barbara Nay, R.N.
The program sends a nurse to patients' homes within 48 hours of discharge - the time frame when medication errors and other problems can cause things can to go awry for the patient.
"The home visit is critical," says Barbara Nay, R.N. "Just seeing someone open up the big bag of medicines they've been sent home with – sometimes 12 to 24 different pill bottles – you can't replace just seeing this and what the patient faces trying to understand it all. I make sure they understand how to take their medications."
Nay also makes sure patients can get to any needed follow-up appointments. If they don't have transportation, she will connect them to community services for help. Sometimes she refers people to rehabilitation programs or mental health and alcohol or drug counseling services. She also teaches patients to recognize and respond to red flags – such as when a call to 911 is really needed.
Nay also makes sure patients are able to get to any needed follow-up appointments. If they don't have transportation, she will connect them to community services that can help. Sometimes she refers people to rehabilitation programs or mental health and addiction services. And she teaches the patients to recognize and respond to red flags – such as when a call to 911 is really needed.
"An important aspect of the program is that we work with patients to set up their own health goals and we help them reach those goals," Nay says.
Nationally, the hospital readmission rate is about 17 to 22 percent for patients with chronic diseases. Although InterCommunity's program is in its infancy, Blasquez estimates that the readmission rate is below 10 percent for the 37 patients the program has served since it was launched in January.
Now, Blasquez says, InterCommunity plans to expand the program to other hospitals in the CCO's service area.