Time to Heal: Hospital to Home program to help reduce the high rate of readmissions

By: Richard Craver - Journal Reporter

Recovering from knee-replacement surgery was a long, aching experience for Lena Kleitches.

Two years ago, she had the replacement surgery, which was supposed to be followed by a four- to six-week recuperation and rehabilitation.

A problem with rehabilitation equipment resulted in a painful wait for immediate help. A later staph infection required that surgeons re-open the knee to clean it out, which stretched her recovery period by two months.

So she was especially worried when it came time recently for replacement surgery on her right knee.

But last month, Kleitches had the surgery, and as she was preparing to go home, Forsyth Medical Center officials asked if she would participate in a new program for the elderly.

Hospital to Home assists older adult patients, primarily those in frail condition, in their recovery to help reduce the "high rate of readmissions," said Kelly Swauger, a co-director of the program.

It is being financed initially through a $322,000 grant from The Duke Endowment and is available only to Forsyth County residents 65 years and older.

"Given how many problems I had the first time, and the fact they would help me get to doctor appointments when I couldn't drive yet, I jumped on the opportunity," said Kleitches, who is not frail but is appreciative of the help and attention.

"They helped me with cleaning, feeding, bathing in those first few days," Kleitches said. "They've been responsive when I need assistance, getting back to me within hours rather than days.

"I'd recommend it to anybody," she said.

The three-year grant enables the hospital to expand the program beyond cancer, heart disease and stroke patients.

It is focused on patients with needs that include physical disability, a history of falls, cognitive decline and those who have had three or more hospitalizations a year. Many of these patients have limited financial and social support; they often live alone or do not have local family readily available to care for them.

Swauger said that the hospital screens for eligible patients as they near time for discharge. Each patient is assigned a navigator who coordinates post-discharge care for as long as four months.

"Patient navigation has been a successful part of the care we provide by helping patients better understand their illness and treatment, and providing an important bridge between doctor and patient," Swauger said.

Part of the home care is being handled on a contract basis by Right at Home, a state-licensed home-care agency. Among the services it provides, on a limited basis, are assisting with grocery shopping, meal preparations and transportation to medical appointments.

Swauger said that the program has served 15 patients in its first three weeks of operation. It expects to serve up to 200 in its first year and 800 over the three years of the grant.

"This program helps our older residents to maintain their independence by providing individualized care during their recovery period, which improves their quality of life and reduces the need for readmission to the hospital," said Crystal Redding, a co-director for the program.

Swauger said that the program may not be right for every elderly patient because it is geared toward short-term care. Those with long-term care issues may do better in a rehabilitation center, she said.

Wake Forest University Baptist Medical Center has provided a similar service since the early 1990s, said Dr. Jeff Williamson, its section head for gerontology and geriatric medicine. Its service involves physician and nurse practitioners.

"We have cared for well over 1,000 Forsyth County residents in that time," Williamson said. "It is also used to train medical students planning to enter the field of geriatrics about the value of home-based care.

"Our program is quite successful at preventing hospitalization, but is limited to less than 100 people since it is supported primarily by gifts from the community and a limited amount of Medicare reimbursement."