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"Caring is the core of this program"

- Virginia Savage, Director of Community Case Management, education and Nursing Informatics


Sentara Obici Hospital

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 Program.

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 patient.

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 health successfully.

"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 Program
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 need.

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 diabetes patients.

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 said.

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 basis.

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 date.

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 are served.

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.

Keys to Success
"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 said.

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 that."

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, they said.

Following Sentara Obici Community Hospital's Lead
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 Stoneburner said.

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.

About Sentara Obici Community Hospital
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, Virginia.