Although elderly, she had been living alone, enjoying independence with minimal support — until a health crisis made her a patient at Dignity Health Sierra Nevada Memorial Hospital (SNMH). After discharge, she would need additional help before she could return to her former lifestyle.
Making certain that she got that help is the role of the hospital’s team of nurse case managers.
In this instance, the patient’s family lived elsewhere, explained Trang Tran, RN, MSN, who worked with family members to find a local assisted living facility where the patient would be well cared for while regaining a measure of her independence.
Tran and other case managers meet with every patient admitted to the hospital to determine what needs they may have and how to help them. About 60 to 70 percent of them will need assistance, she said. That number is growing, reflective of the elderly population that enjoys the Grass Valley/Nevada City community.
“Like the other case managers, I see myself as an ultimate advocate,” Tran said. “I bridge the gap between the health care system and individual needs of people in the community. Our health care system is complex and hard to understand, and while patients are recovering in the hospital, I am maneuvering to the best of my ability to make certain the system will meet their needs.”
Those needs can cover a wide range, from transportation to medical equipment to home or institutional care.
As illustration, Tran described how she managed her workload of 20 patients on a recent day. Ten were discharged. Of those 10, four needed an assisted living facility and were connected with the hospital’s home health agency. Two were referred to the FREED Center for Independent Living. Two received referrals to a visiting caregiver who would help them manage their medications. Twenty-four hour care was set up for an aged woman who returned to her own home. One went to a transition facility where she would get short-term rehabilitation services. In addition, Tran made numerous follow up appointments for the patients, and arranged to pay for one person’s discharge medications through the hospital’s charity fund.
“Our common goal is to support our patients’ needs while promoting optimal health outcomes,” Tran said.
Case managers at SNMH work within a community-wide network of agencies designed to provide care for discharged patients. Included are a number of independent, co-housing, and assisted living facilities. The rehab/nursing homes typically used to provide patients with short-term transitional care include Wolf Creek Care Center, Springhill Manor, Crystal Ridge Care Center, and Golden Empire.
When transitional beds aren’t available, case managers must search for them in other communities, including Auburn, Roseville, Sacramento, and Yuba City.
They also work with local organizations like FREED, which maintains a Care Transition Intervention program now funded by a grant from Dignity Health. Tammy Veralrud is the program’s coordinator and care transition coach.
“Our goal is to keep individuals in their homes after they leave the hospital, and prevent avoidable readmissions,” Veralrud explained. “We do this with a home visit and a series of follow up calls.”
The program helps discharged patients manage their medications, get to required doctor appointments, and make plans if red flags appear in their recoveries. FREED also helps patients connect with needed community resources and overcome barriers associated with disabilities, transportation, and lack of financial means.
Under terms of the Dignity Health grant, FREED works in cooperation with Western Sierra Medical Clinic and Community Recovery Resources (CORR).
In the 18-month period ending in January 2014, the intervention program assisted 112 people, according to Veralrud. Only seven of them required hospital re-admission within thirty days of their discharge.
Lack of health insurance benefits is one of the greatest challenges faced by patients entering the hospital, Tran said.
“Some people lack benefits or financial resources, others have limited social support from family and friends,” she added. “Every patient who walks into our hospital is assigned an RN case manager, because we can identify those barriers that might impede their healthy progression.”
In her words, care transitioning ensures that the physical, social, and psychological needs of every patient discharging to community care are met.
Aside from her professional commitment to the task, Tran revealed that she is motivated by something very personal.
“I realize my own parents will be in the place where they need to transition one day, and having people in my role, and other health care professionals to help their transition, keeps me motivated,” she shared. “The appreciation I get from families, even for just helping their aging parents make medical appointments, makes the difficult cases worth it.”
All physicians providing care for patients at SNMH are members of the medical staff and are independent practitioners, not employees of the hospital.