at your service Community care navigator assists vulnerable patients Lawrence Memorial Hospital initiated a new program in March to extend health and wellness services beyond the hospital walls. The community care navigator program aims to achieve a continuum of care and optimal health for vulnerable patients at risk for complications after going home from the hospital. Linda Gall, MSN, RN, ACM, director of the care coordination department at LMH, says the new program, which is funded by the LMH Endowment Association, links hospital care, primary care, specialty care and community resources in a coordinated effort. The goal is to improve the continuum of care for underserved patients suffering from complex medical and social conditions in order to produce quality health outcomes and reduce preventable hospital readmissions. Linda points out that, on a national average, one in five hospitalized patients experiences complications after going home. Patients sometimes find their recovery at home more difficult than anticipated and may require additional services.Research has shown that hospitals which make discharge phone calls to patients following their hospitalizations can reduce readmissions between 20 and 30 percent, while at the same time increasing patient satisfaction and compliance with primary physician follow-up visits. “Discharge calls produce better clinical outcomes and are the right thing to do for patients and families,” she says. “It’s also a great way to verify that patients understand post-care instructions, which in turn
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As community care navigator at LMH, Kristen Byington follows up with patients who may have complications or questions following their discharge from the hospital.
promotes successful continued recovery at home.” Kristen Byington, a social work graduate student at the University of Kansas, is serving in the role as LMH’s first community care navigator. She attempts to contact patients who have been identified as being at risk for complications within 72 hours after their hospital discharge. Byington discusses their discharge instructions to assist patients in their continued recovery at home, encourages them to follow up with their primary care providers, and assesses any needs for community resources. Some of the resources she has arranged for patients include transportation for appointments, prescription assistance,
in-home meals, Health Care Access and Heartland Clinic referrals, and in-home care programs. Linda reports that the program is accomplishing its goals. In the first five months, Kristen completed 149 phone calls with 99 patients after discharge, and she made 93 referrals to community agencies. Only nine patients out of the 99 who were contacted had an inpatient readmission within 30 days, which is a 6 percent readmission rate. The expected 30-day readmission rate for Medicare inpatients nationally averages close to 20 percent, Linda says. “Most importantly,” she emphasizes, “the community care navigator program is enhancing and saving lives.”
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