Salem Hospital Partners with Northwest Senior and Disability Services

December 22, 2011 -- Reducing hospital re-admissions – particularly among older patients and people with disabilities—and providing tools that empower individuals to be more engaged in their health are the goals of a pilot project under way by Northwest Senior & Disability Services (NWSDS) and Salem Hospital.

"I can coach the patient to become an active member of the healthcare team by having them complete a personal health record,” said Mary Hoffman, an RN with NWSDS, who recently finished a training program known as the Care Transitions Intervention Model. “This record is one place where the patient can write their health conditions, red flags, or symptoms to monitor, medication allergies and questions for their doctor. The record is a tool the patient can use to communicate with their doctor."

Visiting patients at home after they’re discharged from the hospital, Hoffman uses standardized, diagnosis teaching tools to help patients know the "red flags" associated with a worsening of their condition and encourages them to seek medical advice before their condition deteriorates to the point of re-hospitalization 

And, she makes sure they understand what medicines they need to be taking and when; a challenge for patients particularly when new medications are introduced during a hospitalization.

The training program Hoffman completed taught her the importance of coaching patients through four specific self-management skills -- medication self-management -- use of a personal health record -- timely follow-up with their primary/specialty care provider after discharge and understanding the symptoms that might indicate their health condition has worsened and how to respond.

Hoffman spent the last 17 years working with Salem Hospital’s care team in another role at NWSDS.  “They (the Salem Hospital staff) have been very supportive of this program,” she said. “They’ve been wonderful to work with in getting this project up and running."

Tanya DeHart, the community programs manager for NWSDS, is pleased Salem Hospital is interested in supporting seniors and people with disabilities by partnering on this project. “This effort augments whatever discharge plans have been established for a patient, they do not take the place of other needed services and supports,” DeHart noted.

Dr. Eric Coleman, developed the Care Transitions Intervention model, which has been used by more than 270 healthcare organizations nationwide. Studies have shown it can have a sustained impact on reducing unnecessary hospital readmissions. In 2010, the National Quality Forum endorsed the model as a preferred practice for high-risk chronically ill older adults.

For more information on the Care Transitions Intervention Model visit: http://www.caretransitions.org