An example of how Spring Hills continues to make a difference and bring value to the lives of the patients and populations we touch.
Here is a Spring Hills care value story highlighting the collaboration between the Spring Hills Post-Acute Care Team and Spring Hills Population Health team:
Patient is an 81-year-old male with a past medical history of HTN, DM2, Depression, Obesity, CAD, GERD, Myocardial infarction, optic atrophy, and falls. The patient lives alone, however, he has the support of his brother-in-law and close friends for needs such as grocery shopping, transportation, and picking up items in the community. The patient was admitted to Spring Hills Woodbury post-acute care from Cooper University Hospital Trauma division on 10/05/2021 after experiencing a fall. The patient remained in the facility until 10/18/2021.
The Population Health nurse called the patient to perform an initial nursing assessment within 24 hours of the patient being discharged from rehab. The Population Health nurse called the patient’s home number on 10/19/2021 and a friend picked up the phone. The friend, who was also an older adult, stated the patient was lying on the floor and had been there since early that morning and had gone all day without food. The patient and his friend verbalized that the patient was unable to care for himself. The patient’s friend was not able to lift the patient off the floor. While the patient was on the ground with his friend staying by his side, the Spring Hills Population Health nurse notified Spring Hills Population Health social work of the situation. Together, nursing and social work ran through scenarios quickly to be able to assist the patient with the safest care plan. Since the patient had just been discharged from Spring Hills Woodbury post-acute care 24 hrs. prior, the Population Health team called the admissions office to begin the process of readmission.
After speaking with Woodbury’s MDS and Admissions teams, Population health learned that the patient was denied a continued stay in rehab from insurance. Spring Hills social work put a call out to the insurance caseworker for a new authorization to return to the building.
The Population Health nurse called 911 for lift assistance. After notifying 911, Population Health nurse called back the patient at home and remained on the phone prior to and during EMTs arrival. The Population Health nurse gave reports and collaborated with EMTs on-site to ensure patient safety. The patient and his friend were extremely thankful that Spring Hills Population Health was providing this level of support while they were experiencing a traumatic event.
Admissions from Woodbury immediately helped in the case. The director faxed all clinicals to the insurance company for authorization. Population Health social work called the patient and his friend to provide support as well as, discuss financial eligibility for long-term care or the possibility of paying privately for a return to Woodbury post-acute while we awaited insurance authorization. Population Health social work and nursing both discussed how it would not be safe for him to remain at home alone another night. The patient was agreeable to return to inpatient rehab for skilled nursing care paying privately. Admissions kindly stayed after hours to get the room ready and put all paperwork out to the floor for nursing to be ready to accept the patient back.
Spring Hills Population Health social work and nurse secured urgent transport via Gem ambulance for that same night. The patient’s friend stayed by his side and provided him with a meal while awaiting the transport ambulance. Upon arrival at the home, the transport team had difficulty safely getting the patient into the wheelchair van and canceled the transport without notifying the Population Health team, however with the use of our 24/7 on-call support, the friend was able to contact the Population Health nurse and have a new transport scheduled for the same evening.
The Population Heath team ensured that the patient made it there safely. Spring Hills Population Health also uncovered that there was a lack of understanding of how to use a Life Alert device. By uncovering additional gaps in healthcare literacy, the Spring Hills Population Health nurse was able to educate further on the usage of the device.
The social work team at Woodbury is actively working with the patient and a family member to find him an assisted living that meets his financial requirements as well as his social and clinical needs. Social Work is also looking into Medicaid Long-term care supports and services. Social work is providing the patient and family ongoing support through engagement, advocacy, and referrals to needed resources. The Population Health team will continue to support and provide services to the patient throughout his 90 programs.
As a cohesive team striving for the same patient care value goals, Spring Hills Population Health and Spring Hills Post-Acute care were able to come together to provide quick and comprehensive care. It is nice to see how multiple offerings of our company pull together for the safety and well-being of our patients. We are thrilled that this patient avoided hospital readmission and was able to get the care he needed.
Written by Andrea Diblasi PH Dir of Nursing and Christa Fries Dir of Social Work.