Helping the medically frail stay safe at home
Patients have complex medical, psycho-social needs
For some patients Sally Neff, RN, BSN, sees, something as simple as calling their physician for an appointment presents challenges they can't overcome.
"The telephone systems in most physician offices require them to push this button and that button to find the person they want to talk to, and they simply cannot do it. They often ask me if I can call their doctor for them. It's hard for people to navigate our complex health care system," she says.
As a community nurse case manager for Valley Health in Winchester, VA, Neff coordinates care for medically frail, indigent patients with complex medical and psycho-social needs.
The community case management program aims to prevent hospitalizations and emergency department visits and help patients live safely at home.
"Above and beyond that, our program moves into a realm that is so fundamental to nursing - caring for people who need a lot of help. Once you get outside the walls of the hospital, it's an eye-opener to see how people live and what little they have to get by on. These patients don't know how to access care. Many can't see very well, so they get confused about their medication. We help stabilize them, so they can stay at home where they prefer to be," she says.
The community case management program is part of Valley Health's home health division and coordinates care for patients from three hospitals, Winchester Medical Center, Warren Memorial Hospital in Front Royal, and Shenandoah Memorial Hospital in Woodstock.
The program is free for patients who meet the criteria.
Patients eligible for community case management are medically frail with unmet nursing or psycho-social needs but don't meet the criteria for hospice or home health. They must be 18 or older, live within 25 miles of the hospital, and have a primary care provider. They must have been hospitalized two or more times or made three or more emergency department visits in a six-month period.
"Many of our patients live alone with a limited or non-existent social support system. They have no family or limited family or the family lives a long way away or chose not to be involved in their care. I'm the only person some of the patients talk to during the week," she says.
Referrals come from the nurse case managers at the referring hospitals, from home health nurses, physicians, social service agencies, and free medical clinics in the community.
"We have a very strong case management program at Winchester Medical Center. The in-house case managers are very familiar with the assistance we offer and consider us as well as home health for patients who need help after discharge," she says.
The home health agency also has a nurse in the hospital who works with the doctors and case managers on the discharge plan and helps determine which patients are appropriate for home health and which should be referred to the community case management program.
"The case managers are very careful to refer patients to the appropriate program for post-acute care. Home health is a revenue-generating program and we are not. Patients who need injections, wound care, blood draws, and other hands-on care are referred to home health, and we follow up to help them manage their care after home health if they qualify for the program," she says.
The community case managers work hand in hand with the home health nurses to make sure the patients get what they need.
For instance, a home health nurse may be releasing the patient because his or her wound has healed and refers patients to community case management because they need assistance with medication compliance, food, housing, or other help. If the patient is rehospitalized, he or she may receive home health services again after discharge.
"Some patients rotate between home health and community case management. We get to know them well," she says.
When Neff gets a referral, she sets up an appointment with the patient, visits the home, and conducts an assessment that she uses to develop a plan of care.
"During that first visit, I explain the program and make sure that the patients understand that there is no cost to them. My patients live in a world where they have so little money that I make it clear that the program is free," she says.
During every visit, the case managers conduct a series of assessments that cover cardiovascular issues, respiration, pain, and other health care issues. "We develop a plan of care that is based on what we determine to be the patient's main needs. When we visit the home, how the patient is presenting determines what area we focus on that day," she says.
"These are not people who can take a hand-out and read it. Many have problems with memory or are illiterate. We teach in the moment if they have misinformation or [are] confused. We repeat what we're trying to teach every week, and eventually, they understand," she says.
Many of the patients need help in managing their medication. Neff sets up medication boxes for many of her patients and works to help them understand when to take what medication.
"Medication reconciliation is a focus of each visit. Because multiple doctors frequently are involved in the patient's care, polypharmacy is a risk, especially when combined with the patient's mental and visual deficits," she says.
Neff reviews and discusses the patient's prescription medications as well as over-the-counter medications and keeps a list in the home and on the patient's chart. She updates the list at every visit.
Most of the patients have chronic illnesses such as chronic obstructive pulmonary disease and heart failure with diabetes as a comorbidity. Many suffer from depression or other psychological disorders, such as dementia.
"Dementia is huge. Many patients with severe short-term memory loss can function enough to fix their own meals, but when their condition starts to exacerbate, they get really anxious. If we can keep them calm and help them with things that are too complex for them to manage, we can help them stay in their homes, where they want to be, and where it is less costly," she says.
During each visit, Neff educates her patients on their diseases, how to manage them, and their treatment plan.
Seeing the patients face to face helps Neff evaluate any problems patients are having and help them see a doctor if necessary. Often it takes just one look for her to know there is a problem.
"I can contact the doctor and get the medication adjusted or set up an appointment for the patient early on before something evolves into an emergency department visit or results in hospitalization," she says.
She gets local social agencies involved to help with meals, housing, transportation, and programs that help with utility payments.
"These patients are so limited financially. I help them sign up for programs that can help them stretch their tiny check further," she says.
They work from home, use a laptop computer to transmit information to the health system's database, and go to the office only for meetings, educational inservices, and supplies.
For some patients Sally Neff, RN, BSN, sees, something as simple as calling their physician for an appointment presents challenges they can't overcome.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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