A patient’s journey navigating through a complex health system doesn’t begin and end with their hospital stay, but continues as they transition back into everyday life at home. For patients with chronic diseases and illnesses, there are often challenges that hinder them from experiencing improved health, which can result in hospital readmission.
That’s where caregivers working together on a patient’s behalf can truly make a difference. At the Piedmont Clinic, the care team focuses on reducing avoidable hospital readmissions.
A 94-year-old woman suffering from congestive heart failure and dementia was hospitalized repeatedly throughout 2016 and early 2017. In April, she was discharged from Piedmont Fayette and that’s when she was connected to Loretta Lane, RN, Clinic care manager, Population Health.
On their initial call, Loretta discovered that the patient did not remember her education on congestive heart failure. “We spent an extensive amount of time going over the importance of daily weight checks, her sodium and fluid restrictions, and all of her medications,” Loretta shared. “I was also in communication with her daughter and we ensured she was still enrolled in mobile paramedicine, which is a huge asset for patients when they are discharged.”
Through the paramedicine program, paramedics visit patients in their homes to provide education, answer questions and offer additional support. They also administer medications when necessary. “We are diligent about being present with the patient for at least 30 days, so they don’t sneak off to the hospital before we can address their issues or concerns,” said Mary Sloan, a paramedic. “I visited this patient frequently because of her dementia – she would often forget what we explained to her. I wanted to keep reiterating that I was there for her.”
At one point, the patient was admitted to Piedmont Fayette for pneumonia. After she returned home, Mary realized she was still not well. “She told me, ‘I’m just going to go back to the hospital – I don’t feel good,’ so that’s when I reached out to Melinda,” Mary explained.
Melinda Broxson, RN, is a high-risk transitional care coordinator who assists patients before they are discharged by addressing their needs for the first month of transitional care.
The patient has now gone more than a month without readmission to the hospital. “We provide education on every call to make sure she understands how her medications work,” Loretta said. “We were able to get her a scale and her weight has improved. While recent illnesses have taken a toll, our collaboration together has made a difference in her overall health.”