Community program yields big results with volunteers
Hospital targets just 10 people, saves ED costs
Rural case managers looking to bolster community-based programs but lacking staff or financial resources may be able to turn to specially trained volunteers who regularly visit patients at home.
That's how West Georgia Medical Center in LaGrange, GA, has "saved tens of thousands of dollars in emergency department (ED) costs and reduced hospital readmission rates," says Mary Lynn Faress, MBA, RN, vice president of patient services at West Georgia.
West Georgia's home care visit program, called Care-Link, was implemented in January 1995. The initial target group consisted of 10 high-risk patients from a variety of payer sources who visited the ED at least 10 times in a 12-month period. The 276-bed rural facility serves west Georgia and east Alabama and has a 14% elderly patient population, which is higher than Georgia's 10% statewide average.
"The first patient enrolled in the project has visited the ED only once in the first 18-month period," says Faress. Although clinical and cost outcomes are not available, Faress says the hospital plans to expand the program to other target patient groups, such as diabetes and high-risk pregnancy. Care-Link currently has two patients from the original ED patient group enrolled in the program.
One of the reasons for West Georgia's success in reduced readmissions and ED visits is the frequent home visits made by college-age participants in a federal assistance program called AmeriCorps National Civilian Conservation Corps (NCCC) in Washington, DC. AmeriCorps is modeled after the Peace Corps program introduced in the 1960s. In exchange for a year of community services, members receive a living allowance and an educational grant of $4,725 from the government.
Participation in Care-Link is voluntary and free to patients, notes Faress. Care-Link has three goals as part of an effort to coordinate care delivery over time in various settings. Goals include:
* improvement in patients' self-reported health status through teaching patients self-management techniques;
* reduction in the number of hospital readmissions of these patients;
* decreased visits to the ED.
Patients must sign an agreement stating that they will follow the care plan coordinated by the nurse. "These patient groups are typically underinsured or lack a network of family support. They also may not comply with their prescribed medication regimen," she explains.
Clinical needs, such as lab tests, are coordinated by the hospital's designated nurse for the Care-Link program, who also serves as coordinator of the inpatient case management program. The Care-Link case manager's position currently is part time, but may be expanded in the future to full time as more patients are enrolled, says Faress.
Patients are referred to the program by their primary care physician, hospital social worker, or home health nurse. The hospital Care-Link case manager coordinates referrals to community-based organizations or hospital-based services after the patient is enrolled in the program.
Besides the nurse and the patient's primary care physician, patients receive care from the following hospital-based disciplines:
* patient education;
* dietary;
* physical therapy;
* pharmacy;
* social services.
If patients have concerns about their medication, for example, the case manager schedules an appointment for the patient to discuss medications and side effects with the hospital pharmacist. Or a patient simply may need transportation to a physical therapy session. The AmeriCorps member often coordinates the service, explains Faress.
Support and social services, including psychosocial assessments, are managed through the Care-Link coordinator and the AmeriCorps volunteers. The hospital nurse and Care-Link coordinator meet weekly to discuss client needs and interaction. "The volunteers provide services such as meal assistance or checking to see if the patient is following the recommended diet or taking medications. Or the patient may have an environmental need, such as clothing. For example, we've built two wheelchair ramps for patients at their homes," says Faress.
AmeriCorps participants, which include 28 full- and part-time members, document each visit to a Care-Link participant by writing a visit report. Reports are sent to the hospital case manager to include in the patient's file, says Faress. Patients considered at risk of needing home care services or hospital readmission are evaluated in the home by the Care-Link case manager. General health status is determined during the in-home assessment, as well. (See p. 108 for a copy of the assessment.)
"The in-home assessment helps identify what kind of clinical and non-clinical needs the patient has, such as meal assistance or further education. A patient may have a hard time understanding diabetes, for example, so the nurse will arrange to reinforce the education through subsequent home visits by the AmeriCorps volunteer or a home health nurse if necessary," explains Faress.
West Georgia is currently developing an internal database to track Care-Link participants. Outcome indicators will monitor each participant's progress over time, says Faress. Indicators collected by Care-Link providers include the following:
* health status assessment;
* blood glucose levels for diabetes patients;
* complication rates;
* comorbidity rates;
* patient satisfaction results.
West Georgia will likely expand eligibility of Care-Link to elderly patients with chronic conditions and high-risk pregnancies, says Faress.
[Editor's note: For more information about AmeriCorps National Civilian Community Corps (NCCC), administered by the Corporation for National Service in Washington, DC, contact AmeriCorps at (800) 942-2677.] *
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