“People don’t realize how important it is to know your patient, to see them in the home and to learn what the barriers are,” said Tammy Church, RN. “One encounter can’t tell you the whole story.”
Through a grant awarded to the Cheyenne County Clinic in St. Francis, Kansas, Church and the EMS director Reid Raile began the mobile integrated health care service, working with high risk patients (patients at risk for complication or admission) in 2016. Church had two goals - to help patients stay safely in their homes and to reduce the number of avoidable emergency room and hospital visits.
“There are so many barriers to care that you can identify if you visit a patient’s home. But first,” Church said, “you’ve got to earn their trust. I’m not going into their homes to take over their life. I just go in with the education. We come up with a care plan and set up a routine. I find frequently that people don’t take their medication as prescribed.”
Church has worked with about 40 patients. Typically they start out with frequent home visits and then transition to semi-monthly or monthly home visits. Eventually they may only require a follow-up phone call to ensure that their care plan is being followed.
Church evaluates their needs, making sure that patients understand why they are taking each medication and the way it is intended to be taken. “I teach them how to read the labels, so they don’t just rely on the color or shape of the pill.” She also compares the prescription list from the clinic with what the patient perceives, setting up a system that is easy to follow. “Medication education is such a huge piece of the pie.”
However, her work to assist high risk patients goes well beyond monitoring prescriptions. It may include assessment for dementia or making sure a patient understands the appropriate technique for their breathing treatments. She may be helping Veterans who have trouble getting their medications or assessing a person’s fall risk – in which case she may get grab bars installed in showers or throw rugs removed. She looks for fire alarms and carbon monoxide testers, too. “Sometimes going in with a fresh set of eyes can make a difference,” she adds.
It is useful that she can do documentation in the patient’s clinical chart, so the provider can review what is taking place in the home. It also provides direct communication for Church and the provider, so Church can share her recommendations or concerns.
Her services are valuable for patients’ mental health, too. “People who don’t get a lot of visitors look forward to the visit,” she said.
To get past additional barriers her patients face, Church will access other services in the community such as scheduling a housekeeper, doctor or physical therapy appointments or arranging transportation through the community van. Patients who are able to stay at home but are nearing the end of life can turn to Church for assistance to line up hospice care. All of these efforts cut back on the need for frequent visits to the clinic or the emergency room and reduce the demands for more expensive resources such as admissions to hospitals and long term care facilities.
There is a wide range of community resources that Church calls on for assistance, including the clinic, the ER, home health, the sheriff, adult protective services, the pharmacists, the State, whatever it takes to improve the health and safety of patients who want to remain at home. “I think it is neat that all the departments are working collaboratively to help the patients stay in their homes safely. Sometimes they need just the point person to get the ball rolling.”
Patients come to Church through provider referrals from the clinic, when discharged from the hospital or through Home Health Services. Cheyenne County Clinic offers the mobile integrated health care services to any patient of the clinic within Cheyenne County. The clinic comprises two physicians and three physician assistants. Cheyenne County Clinic has been an early partner of the Kansas Practice Transformation Network, working with Mary Monasmith, Kansas Healthcare Collaborative Quality Improvement Advisor.
“I think all the success stories brought about by this mobile integrated health care service are keeping costs down,” Monasmith said. “It’s keeping patients out of the emergency room and it is improving their health.”
Church has a number of successes that bring her a sense of accomplishment and satisfaction.
One diabetic patient had frequent visits to the emergency room because she didn’t take her medication properly. When a fall resulted in a wound on her foot that wouldn’t heal, the patient needed surgery, but had no family or support, no one to drive her. Church took her to Denver for the surgery and stayed with her for two days, then brought her home. “They were able to save her foot.” When Church first started seeing this patient her hemoglobin A1c was above 9 and now it is under nice control at 7. Church continues to see this patient weekly. “She takes her medication accurately and she is no longer insulin-dependent.”
Another positive outcome involved a patient who was seen at the clinic several times for neck pain and chronic pain medication. After a visit to the ER for pain and numbness, he was admitted to the hospital and referred for surgery. After surgery, all pain medication was discontinued. “He had been taking quite a bit of pain medication, but you can’t stop cold turkey. He didn’t want to be addicted to those pain meds. He was just trying to reduce the pain.” Church consulted with the primary care physician and set up a pain management program, gradually decreasing the dosage. “Now he is completely off the pain medication, has no more numbness and is back to work.”
The benefits of mobile integrated health include a reduction in emergency room visits and hospital stays and an improvement in patient outcomes and overall health. The bad news is that the grant that launched the program has expired. Church said there are enough private funds to carry on a little longer, but how long is hard to tell. “I think the program is very beneficial to the people of this community. I will be sad if we can’t sustain it.”