"Caring is the core of this program"
- Virginia Savage, Director of Community
Case Management, education and Nursing Informatics
Low income patients with diabetes or heart failure
who don't meet the criteria for home health care can be at
particularly high risk of complications and poor outcomes, but
those living in the community served by Sentara Obici Community
Hospital have a distinct advantage: The Community Health Outreach
Developed to meet the needs of individuals with income below 200
percent of the federal poverty level who are suffering from
diabetes or heart failure, the Community Health Outreach Program
helps those individuals navigate the complex healthcare system, and
provides an interdisciplinary approach to care to improve the
likelihood that medical care plans are followed. But the nurses who
provide the services do much more than that. In many cases, the
nurses are the only source of social and emotional support for a
One such patient is "Joe," an alcoholic who presented for care at
the hospital when he was homeless and sick. He was referred by the
hospital for services, and a program nurse, who had cared for him
in the hospital, became concerned when he didn't show up for an
appointment. She set out - literally - to find him. She did find
him - in a ditch lying in a half foot of water. The concern and
persistence she lovingly showed "Joe" in that true hour of need,
changed his life. The nurse ensured that he received the care he
needed, and the help he needed to manage his health and his
struggles with alcoholism. Today "Joe" is sober, and managing his
"Caring is the core of this program," said Virginia Savage,
Director of Community Case Management, education and Nursing
Informatics at Sentara Obici Community Hospital.
The Community Health Outreach Program was conceived in 1998 when a
Diabetes Continuous Quality Improvement Team study found that
patients with Diabetes - particularly indigent patients - were
frequently in the Emergency Department or admitted as an inpatient
due to uncontrolled Diabetes.
The Outreach Program's guiding premise was that individuals with
chronic diseases, specifically Diabetes, will adhere to their
medical plan of care if they have the knowledge, financial
resources and social support they need to manage their health.
Caring for and about the individuals in the Outreach Program is the
core of the program, according to Sentara Obici's Hospital
Charitable Service Awards application.
"We learned that if we go into their home, drink coffee with them,
and just listen - they will tell us what they need, and if they get
what they need, they will take care of themselves," Savage said.
"We have patterned our program by that."
Community Health Outreach partners with "every agency possible" to
ensure those needs are met. From Legal Aid, to Free Clinics, to
counseling services, to utility companies, the program works to
gain the support of the entire community in serving those in
Early outcomes associated with Community Health Outreach were
remarkable. The hospital foundation reported a 48 percent decrease
in emergency department visits, a 68 percent decrease in hospital
inpatient visits, a 60 percent decrease in length of stay, and 55
percent decrease in hospital charges. Thanks to these outcomes, and
subsequent funding of the program, it has grown from one full time
registered nurse to four full time nurses and one full time
Community Encourager who provide outreach to heart failure and
The number of open cases ranges from 98 to 135 depending on the
intensity of care needed to help patients attain disease control.
Patients are referred to the program by cardiologists, primary care
physicians, and Home Health. Of the more than 1,500 patients who
have been served by the program since its inception, 38 have been
involved for as many as 11 years without an emergency department
visit or inpatient admission. These are patients who require
coaching on an ongoing basis, but most individuals are able to
control their disease at home once they have the knowledge and
resources they need to follow their medical plan of care, Savage
In 2008, additional grant funding allowed for the purchase of
Telehealth In-Home monitoring equipment that extended the program's
reach to clients who live at distances that would be prohibitive if
frequent home visits were required. The equipment has proved
instrumental in helping patients become even stronger partners in
their own disease management, because they see monitor their own
weight, blood pressure and blood glucose levels on a daily
In 2009, the program was further expanded to include a 6-week
Chronic Disease Self Management Class developed by Stanford
University. Seventy-one individuals have completed the class to
Since the program's launch in 1998, not a single patient has
needed an amputation, and the nurses who serve through Community
Health Outreach have also helped ensure - through strategic
community partnerships - that client's needs for shelter, clothing,
food, water, heat in winter and relief from heat in summer
The key is to remove the barriers the patients face, to teach them
what they need to know, and to make sure their basic needs are met
so they can be in control of the disease process, rather than it
controlling them, Savage said.
"Community Health Outreach is more than just a case management
program," said Phyllis C. Stoneburner, Vice President of Patient
Care for Sentara Obici Community Hospital.
The program nurses oftentimes become like family to the people
they serve. That level of care makes all the difference, she
Meeting the patients where they are - both physically (in their
homes) and emotionally and socially (to identify their needs and
barriers) - is also key.
"You hear healthcare people talk about patients who are
'noncompliant,' but usually that's because there are issues in
their life that they have to prioritize, and they don't know how to
reach out for help," she explained. "We can't be successful if we
don't meet them where they are."
Partnering with community agencies and organizations is also
extremely important for success. These patients have many and
varied needs, and meeting those needs requires strong relationships
in the community, Savage added.
"One thing we have to be cognizant of is that the people we come
in contact with are very proud people. They don't want to say they
can't get a prescription filled … we have to advocate for them with
the right agency so they can feel comfortable in getting resources
for themselves," she said.
The support of the hospital administration is another necessary
component for the success of Community Health Outreach.
"Our hospital administration has been extremely supportive of this
program from day one," Savage said. "We had grant funding for most
of our nurses' salaries, but we needed office space, office
supplies, medical supplies … the hospital has supported all of
The hospital, like the program nurses and the community, are
heroes for caring the way they do about those in the community who
need these services, Savage and Stoneburner agreed.
Other heroes include the Obici Healthcare Foundation, which also
provides funding, the people - including many physicians and nurses
in the community and hospital - who refer patients to the program,
A number of lessons have been learned in the development of the
Community Health Outreach program that would be useful for other
hospitals considering launching a similar program, Savage and
First, every person in the community with a chronic disease must
be viewed holistically by those who provide healthcare. That is,
the individual shouldn't be viewed based just on his or her
immediate health needs, but in terms of the resources needed to
ensure that barriers to successful healthcare and chronic disease
self-management are removed.
Next, be sure that when you are hiring nurses and others to
deliver program services that they have a truly nurturing
personality and are willing to go that extra mile for those they
serve, they advised.
And finally, the development of a network of community agencies
and organizations to help in meeting patients' needs is imperative.
You really have to know what's available in the community - and
reach out to ask for it, they said.
Sentara Obici Hospital is a 168-bed acute care hospital located in
Suffolk, Virginia. While it opened its state-of-the-art facility in
2002 and merged with Sentara Healthcare in 2006, the hospital
continues a 50-year tradition of providing residents of Suffolk and
Western Tidewater with patient-centered care. As the community
grows, so too does the hospital. In June 2010, Sentara Obici
Hospital opened a new three story 64,380 square foot wing with all
private beds. Sentara Obici provides 24 hour Emergency Care, and
Advanced Imaging in the form of MRI and CT scans. The hospital
provides the following services: Cardiac Care, comprehensive Cancer
Care, Neurology and Sleep services, Inpatient and Outpatient
Surgery, Breast Health Center, and Rehabilitation Services. The
nearest tertiary medical facility is Sentara Norfolk General
Hospital which is approximately 35 minutes away. The hospital's
original Charter mandated that the Hospital provide care to all who
needed it regardless of race, creed or their ability to pay. Amedeo
Obici, the founder of Planters Nut and Chocolate Company, was also
the founder of the hospital, which he built to honor his deceased
wife. His wish to improve the health of the community has remained
a tradition at Sentara Obici Hospital. The hospital's Service area
includes a 1400 square mile area in Western Tidewater,