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Program keeps patients closer to home while staying connected to care team

Program keeps patients closer to home while staying connected to care team
“He was ready to do anything to make things easier.”

After years of being in and out of the hospital and Emergency Department, Larry, 84, and Mary Jane, 74, Riffle felt exhausted by their constant visits as Larry faced continual health challenges after a bad accident several years ago. While they always felt they had strong care at Carle, it always seemed he would get the care needed and then somehow find a new problem a couple weeks later – or sooner.

Its patients like the Riffles that Carle clinical leaders had in mind when developing the Transition at Home program. By offering patients with a tendency to return to the hospital after an acute stay a built-in way to maintain a more present connection of support with providers, patients feel more cared for and are more willing to complete the aftercare recommendations that help keep them recovering well in their home setting.

Mary Jane is proud to be Larry’s primary caregiver, and wife of 54 years, but she recognized they needed additional help to reduce the boomerang effect they were experiencing. So when they first enrolled in the Transition at Home program, she felt a sense of relief.

“Janice [Our nurse practitioner], was just so easy to speak with and so understanding and tries to find a solution if at all possible,” Mary Jane said. “My husband is elder and a lot times you don’t get the care you really deserve but we didn’t feel like that. The best part was she will come to our house, she actually meets the patients and understood everything we were going through. It was really 1-on-1.”

Right now, the program includes a guarantee of 30-days of continuous support from a Transition at home provider or nurse practitioner. Care providers contact patients by phone or in person daily throughout the program to execute the care plan specifically created for each patient. The hope is to help participants recover more completely and transition then transition their care to a Primary Care Provider.

“While we think this framework can improve outcomes for patients with a variety of needs, we are focusing our initial commitments for this work on patients with higher risks, more comorbidities, high medication needs and more complex issues,” said Emily Lyons, Hospital Medicine manager at Carle Foundation Hospital. “These challenges can often lead to the need to be more connected to Primary Care services and this program helps steward that relationship between bigger incidents and regular health maintenance.”

The program offers a lot of patient satisfying aspects like continued access to their doctors and reducing the amount of on-site appointments, and there are clinical outcomes the team leading the program are looking for too. The added connectivity allows providers to look for social trends that may be impacting patient outcomes and connect them with social workers for support. The types of conditions patients participating in the program typically have offer an average hospital return rate of 34%. So far Carle patients participating in the Transition at Home program are seeing less than 32%. The team is hoping to reach an average of 30% as the program continues.  

“Close follow ups after hospital discharge helped patients with medication compliance and better understanding of their disease process,” Sudha Muthekepalli, MD, a provider with the program said. “There is continuity of care with regular telehealth or in person appointments, regular phone call follow ups by the Transitional Care Clinic nurse.”

As Larry and Mary Mane near the end of their program cycle, she finds herself wishing it was longer than 30-days.

“That’s the biggest drawback I really think it could be longer and I really think to iron out some of the health issues if we had more than 30. It’s just really too short,” she said.

But until then, they’ll continue to connect with their favorite nurse practitioner Janice, and try to stay focused on being grateful.

“It is a day by day thing, but each day is a good day.”

If you think you or a loved one would benefit by participating in the Transition at Home program participant, speak with your care team or contact the Transitional Care Clinic at 217) 383-1687.


Categories: Redefining Healthcare, Community

Tags: Community