Transitioning Patients From Hospital To Home

The initial meeting didn’t go well.

When Yareliz Oliveras, the Hospital-to-Home care coordinator, entered the patient’s room, she quickly saw the handwriting on the wall. “When I went in to see the guy, he cursed at me and kicked me out of the room. He didn’t want to hear about any of our services. He just wanted to leave the hospital.”

That didn’t stop Oliveras. Over the next few days, she kept trying to build a relationship with the patient. She would come into his room, without paper or pencil or a computer, simply to say “hi,” and try to gently bridge the gap. “That’s how it usually starts. We get a lot of tough patients.”

The Hospital-to-Home program, re-energized several months ago from when it was known as DSRIP Care Transitions, is about dealing with tough patients. “We work with all patients who need support during their transition home, but we have special expertise in working with complex cases,” says Zoe Stopak-Behr, the program director. “We’re primarily looking for Medicaid patients who have a pattern of being readmitted, who have multiple medical and social needs. Many of these patients face housing insecurity or food insecurity, they may lack access to primary care or need case management services, so we try to link them to services that address the root cause of their hospital utilization.”

In addition to working with patients on various med/surg floors of St. Barnabas Hospital, the program supports transitions for patients on the Kanes (psychiatric units) and in detox.

One Patient’s Story

As an example, consider the case study of one patient referred to the Critical Time Intervention (CTI) program, to which the Hospital-to-Home team is responsible for referring eligible patients:

A young man, diagnosed with schizophrenia, had been precariously living in what was deemed an “unhealthy situation” with his abusive mother. His CTI case manager helped him process his disability insurance and open a savings account at a local bank. The case manager now accompanies the patient to the pharmacy for his medications and has found him a private room to rent. As a result, the patient has started to demonstrate an increased ability to care for himself and tend to his needs. He continues to be engaged in his individual psychotherapy and his medication management, and regularly checks in with his case manager.

The formula is a simple one. “In most cases, it’s about getting the patient’s and the family’s trust and truly understanding them,” says Oliveras. “We dig deeper into the issues they’re having. I think our program is making a difference in their lives, but we need to keep showing them we’re here to help.”

One 60-year-old man was being re-admitted every two weeks to the hospital for his COPD, entering through the emergency department. “He would regularly miss his primary care appointments,” says Oliveras. “We found out that he was not taking his medication, so we got him into our meds-to-beds program and educated him. Additionally, he was living with his girlfriend in an apartment that didn’t have elevators and this was causing him additional stress. We connected him with the Empress Community Paramedic program, so he could receive home visits and treatment at home for a few weeks after discharge. He now follows up with his appointments and has home care services. He’s hasn’t been here for the last four or five months.”

This pattern has been followed by many patients. Christian Cevallos, a care coordinator in the program, helps transition patients who suffer from substance abuse disorder. “I had a heartfelt conversation with a young man, who broke down in tears as he told me about his life,” says Cevallos, who started at SBH eight years ago working in a temporary overnight position in housekeeping and is now attending nursing school at Lehman College in addition to working full-time with the Hospital-to-Home program. “He realized it was time to change his life. He had been in a repetitive situation. He realized he could either choose receiving support or continue his failing routine of cycling through detox.”

Cevallos helped him to enroll in the hospital’s Methadone Maintenance Treatment Program (or MMTP). “I brought him there at 6:30 in the morning to start getting treatment. We got his medical insurance reactivated and got him services close to where he lives. He’s faithfully been going to MMTP, got himself a job and continues to receive the support he needs.”

The Hospital-to-Home program works closely with various service provider organizations around the Bronx. This includes medical support services like Empress Community Paramedics; social service agencies like BronxWorks for those requiring housing assistance or POTS (for Part of the Solution), which provides food pantries; and AIR NYC, for those with asthma.

More recently, during the heart of the Covid-19 pandemic, the Hospital-to-Home team has been staffing the Family Support Center Hotline, which had been opened 14 hours a day for family members of admitted patients – none of whom were allowed access to the hospital because of concerns over exposure – to call to receive updates on their family member’s status.

“At its height we were handling about 75 calls each day,” says Stopak-Behr. “Any questions that were too complex for us to answer confidently we escalated to the relevant attending on the floor. The Support Center has been an incredible lifeline for the family members of Covid patients who are not able to visit their family members, as well as a way to minimize the volume of calls to the medical floors where care teams needed to focus on patient care.”

In an effort to move back towards its core work, while still supporting the Covid response, the team is in the process of obtaining a registry of all Covid-diagnosed patients who were discharged from the hospital.

“We will be reaching out to every one of the discharged patients to see how they are doing, ensure they had a follow-up visit (and to schedule if not), and determine any needs for referral to support for anxiety/depression or other services,” she says. “This will have the dual impact of ensuring patients reconnect to care, as well as gather information about how our patients have fared post-discharge.”

Once completed, the team will return to the hospital floors to restart its regular work.

“Even as we return to the ‘bread and butter’ of the Hospital to Home work,” says Stopak-Behr, “we still plan to maintain the Family Support Center, both the hotline as well as support for an inpatient initiative to connect families to patients by video chat so they can talk to their loved one during hospitalization. We understand now more than ever that support for the patient needs to include support for the family, as well.”