Helping the medically frail stay safe at home

September 15, 2009

Winchester, VA's Valley Health has established a community case management program to prevent hospitalizations and ED visits for frail patients who live alone.

Community case management helps minimize ED visits

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 psychosocial 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 psychosocial 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 nonexistent 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.

This story was adapted from one originally published by AHC Media LLC (800-688-2421).

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