Sierra View reports Bridge Services cuts readmissions

Thursday was the one-year anniversary of Sierra View Medical Center’s Bridge Services program designed to reduce readmissions to the hospital and Sierra View stated on Thursday the program has made a big difference.

There are two departments in the Bridge Service program designed to address needs outside traditional medical center. The Palliative Care Program serves patients with Stage 4 cancer in conjunction with the Roger S. Good Cancer Treatment Center and Dr. Owen Kim, MD. And the newly created Postacute Care Transitions program, PACT, focuses on reducing readmissions for CHF, COPD and Pneumonia patients.

Sierra View stated one key readmission rate has been reduced by 78 percent as a result of the program.

“By addressing social, emotional and financial needs and connecting patients to programs and community-based services, our teams help patients stay healthy at home,” Sierra View stated.

“The PACT program had some amazing achievements in their first year,” Sierra View added. “They started out slowly, defining how they would identify and manage patients.”

There were 100 patients per month who were admitted with CHF, COPD and/or Pneumonia. While not all of those patients were able to participate in the program every admitted patient was evaluated so they would have the best chance of success in the program.

Sierra View stated about 50 percent of the patients were from skilled nursing facilities, had extensive mental health issues, had no ability to communicate via telephone or were unable to participate at a level which would lead to success.

As far as the overall program, Sierra View

stated “Bridge Services team has created a patient engagement process and developed interventions that would address their medical and social needs as well as healthcare access issues. As patient engagement improved they started to see reductions in readmission rates for participating patients.

PACT patients are identified with a daily review of newly admitted patients. Patients meet with the department’s Engagement Specialist, Cindy Sanchez, who presents the program to the patient and/ or family.

Sanchez also completes a basic social needs assessment to help the team create a postdischarge plan of care.

“I feel honored to know that patients feel comfortable talking to me and expressing their concerns about going home,” she said. “And with our process, I am able to see almost 100 percent of the patients identified each day.”

The PACT Team works with Care Integration and the GME Residents/ Hospitalists throughout the patient’s entire admission to create continuous care that benefits the patient and family.

One of the primary successes of the program is with medication for patients when they are discharged, Sierra View stated. Pharmacy Technician Crystal Hurtado has been able to engage more than 80 percent of those patients who were discharge as a PACT patient, the hospital said.

One to two days after discharge PACT patients are contacted to ensure they have received all their medications, help with insurace, and provide additional support if needed.

“The medication reconciliation process helps patients feel more supported in their transition home,” Hurtado said. The patient also speaks with the Pharmacist or the Nurse Case Manager and basic triage is completed to confirm that patients are following the discharge plan and aren’t in medical distress. The hospital stated sometimes all it takes are minor interventions to prevent the patient from returning to the hospital.

“The essence of the PACT Program involves an interdisciplinary approach to help the patient stay healthy at home,” the hospital stated.

Support with social, emotional and financial issues, healthcare education, readmission prevention strategies and how to use community-based programs is provided. The PACT Program works with patients for 30-45 days to ensure they continue to improve.

Many times interventions are “small and simple. Our two most common interventions have nothing to do with medications, but with social factors that affect the wellbeing of our patients: food and electricity,” says Amy Shepard, Clinical Pharmacist. “As both of these continue to rise in expense, it is becoming more difficult for the average household to sustain, especially when poor health forces patients, or caregivers, to work less.”

Information about food distribution programs, and income based programs which can reduce utility bills is provided to patients.

“Many patients have very limited healthcare literacy, and a few minutes getting discharge instruction education is not enough to keep them on track,” says Devon Barlow-merritt, Manager of Bridge Service and RN Case Manager for the PACT program. “One of our main goals is to provide supportive education to the patient and their family so that they start to make small improvements in lifestyle behaviors. We start with basic stop light tools, especially for CHF patients. And we encourage them to discuss changes with their PCP.”

About 60 percent of PACT patients complete the program, but not everyone is ready to make lifestyle changes. Bu for those who participate in the program, the readmission rate within the next 30 days has been reduced by 78 percent, “which is a huge stride to success,” Sierra View stated.

Some of the success comes from navigating patients to the right community-based program, the hospital stated. Anthem Blue Cross and Healthnet have an extended case management program, funded by the California Advancing and Innovating initiative, better known as CALAIM. These extended case management services are for those patients who are high utilizers of acutecare services, homeless or have substance use disorders.

:By connecting these patients to extended services, we have many examples of incredible success. have seen a patient who sought emergency room services 36 times in the preceding twelve months, reduce their visit rate to 4 times in the six months following the referral to CALAIM Extended Case Management. A huge savings in Sierra View resources,” the hosptial stated.

The Palliative Care program is now in its sixth year, having been created originally from the PRIME program. This past year the Bridge services team evaluated how they might enhance and expand the program.

They started by increasing the number of patients in the team’s caseload to 40 and enhancing the services provided by the team. Not only does the Palliative Care Team work with patients on an outpatient basis, but they also provide the social work and case management services needed when these patients are admitted to the hospital. The Palliative Care team becomes close with patients and their families, and the continuous care across hospital services is helpful for their recovery, Sierra View stated.

]“Working with our patients helped me see how positive someone with Stage Four cancer can be,” said Noah Camacho, RN Case Manager for Palliative Care. “My patient wants to go to a fancy dress party, so we are working to get her to a special local event. I started working with the Foundation to help us with this endeavor”.

Lupe Fernandez, the Palliative Care Licensed Clinical Social Worker said, “Getting the news that they have cancer can really challenge the patient’s perception about life and the future. We give encouragement and provide emotional support as well as provide a variety of resources to the patient and their family. From our department’s services like symptom management and nutritional support, to the community resources they sometimes need and don’t know how to access, these can all help reduce the stress associated with a cancer diagnosis.”

Sierra View stated by improving the appointment process to ensure all patients are seen timely and with increased frequency, the rate of patient contact increased by 63 percent and newly referred patients had their initial assessment appointment within 30 days.

Bridge Services also works with Uber and Porterville TRANSPORT to reduce the financial impact of taxi vouchers and help patients use TRANSPORT to provide for more reasonable transportation.

In addition CALAIM has two new communitybased programs: Medically Tailored Meals and Asthma Home Remediation which are referred by Bridge Services staff.

Medically Tailored Meals are available for all CALAIM qualified patients discharging from the hospital for up to 12 weeks at no cost. “This helps with healing and recovery from illness by using healthy food as medicine,” Sierra View stated.

Bridge Services also works with The Asthma Remediation program to reduce air quality problems in the home. The service is free to patients who have been discharged or who have had multiple emergency department visits due to asthma.

The Bridge Services Department consists of: Noah Camacho, BSN, RN-BC, Palliative Care RN; Lupe Fernandez, LCSW, MSW, Palliative Care Social Worker; Amy Shepard, Pharmd; Crystal Hurtado, Pharmacy Technician; Cindy Sanchez, Engagement Specialist; Tiffany Lu, Registered Dietitian;

Devon Barlow-merritt, MHL, BSN, RN, CCM, RN Case Manager for the PACT Program, and Manager of Bridge Services and Dr. Owen Kim, Medical Director for the Palliative Care Program.