Transcription:
Assisting Patients and Families in the Return to Home

Scott Webb (Host): Welcome to Picking Our Brain with Shepherd Center. I'm Scott Webb. And today we're discussing Shepherd's Center's Transition Support Program, which prevents rehospitalization, improves health and safety outcomes and promotes patient and family autonomy once the patient is discharged. And joining me to tell us more about the program is Laura O'Pry. She's a Registered Nurse and Manager of the Transition Support Program at Shepherd Center. So, thanks for joining me, Laura. I want to have you start by telling listeners a little bit about yourself and what you do for Shepherd Center.

Laura O'Pry, RN, BSN, CCM, CRRN (Guest): Just to give you a little bit of background, I started at Shepherd in nursing school and I had a practicum on one of our brain injury units. And I knew right away that Shepard is where I wanted to end up. So, when I graduated nursing school, I applied to become a staff nurse at Shepherd and was hired and worked as a staff nurse for about one or two years. I was then recruited to work in our intensive care unit. And I worked there for several years. Then a position became available as a Nurse Educator on the brain injury units. And that kind of took me back to my roots from nursing school. So I took that position. I did that for several years.

And while I was in that position, I was on a committee and in that committee one day, several staff members and the manager of the Transition Support Program came to speak. And they talked about the program. They talked about the challenges that our clients face when they go home. They talked about the interventions that they provide, and it really resonated with me. I knew that at some point, I wanted to work in that program. I had done the inpatient thing and I just felt a calling and really interesting within that year, the Management Position for the Transition Support Program became available. So of course I jumped on it. I wanted that position and I got it.

Host: Sure.

Laura: I became a Certified Case Manager and here we are five years later in the Transition Support Program. And I've been with Shepard a total of 14 years.

Host: That's amazing and what an amazing journey you've been on. And it's so cool when I get to talk to guests who really had that calling in medicine and just knew this is the right thing for me. And so when we talk about the Transition Support Program, who really benefits from the program?

Laura: So, before I get into that, if you don't mind, let me just kind of explain that the Transition Support Program, and I'll probably call it TSP for short, just so I'm not constantly saying Transition Support Program. It's really an umbrella term for several different departments. So, we have transitional case managers and there are four case managers who report to me. I have one dedicated life skills therapist. I have three vocational counselors and a total of eight peer support liaisons between our spinal cord injury programs, our brain injury programs and our military program. So, in regards to who benefits. Peer support is really available to anyone and peer support can be conducted in many different ways.

So, we meet with patients while they're still in the hospital. We can meet with them if they're enrolled in one of our outpatient programs, we also meet with them virtually. We can reach out to them via text or phone call and we also offer different support groups. One thing I do want to mention is peer support has two Facebook pages. So, regardless of whether you are or were, or never were a patient or caregiver at the Shepherd Center, I would encourage you just to take a look through these Facebook pages. So, for our spinal cord injury population, if you go to Facebook and type in Shepherd Peers, you'll find that Facebook page, if you type in Shepherd BI as in brain injury peers. You'll find our page that's dedicated to the brain injury community.

So those are great Facebook pages and they do a lot of different things. Sometimes they'll post educational videos, which often be very comical. They also will post different community events. And one thing I really like about both of those Facebook pages is that it can be a forum for community members to ask questions to the rest of the community and community members can answer from their perspective. You know, for example, let's say someone is looking for a particular physician, someone else might reply and say, you know what? I have the perfect physician for you. So, I would definitely recommend both of those pages to anyone who's interested.

So, next is life skills and life skills therapy is also available to anyone. Now this does require a referral to the program, and I'll talk a little bit more about that in a few minutes. Life skills really focuses on safety, supervision needs, community re-entry, organization and medication management, just to kind of name a few. And life skills can be in the home and it can also be done via Telehealth.

So, if it's being done in the home, the client must reside within a two hour radius of Shepherd. Vocational counseling is also available to anyone who is interested in returning to the workforce or returning to school. The voc counselors can, and we call it voc for short, the voc counselors can help with anything from career exploration to resume development, job placement, job coaching. And another really valuable thing that they help assist with is contacting employers to ensure that our clients receive the reasonable accommodations that they deserve.

Transitional case management, this is really an extension of the nursing and case management support that our clients were provided while they were inpatient or also while they were in one of our day programs. And this is really only for our high risk population. So, it's not available to everyone. Really those high risk patients and it actively starts when the patient is discharges.

Host: You know, Laura, it does sound like there's a lot of great resources and ways for people to reach out and get involved. And watch some funny videos on Facebook, which is great. So, let's talk about the goals of the program.

Laura: The overarching goal is prevention of re-hospitalization. Once our patients come to Shepherd, they can receive weeks to months of really intensive rehab. And of course, once they go home, we want to keep them at home. We want to keep them safe. And so we do everything we can possibly do to prevent them from ending back up in the hospital.

So, we do that through helping to ensure that by helping to prevent any medical complications. In order to prevent medical complications, we ensure that the patients and caregivers are really following the discharge plan that they were given. And also following the home care instructions that they were provided.

So, we really try to reinforce all of the knowledge and all of the skills that they learned while they were in rehab. For example, one of the things that we really focus on is effective medication management. If our clients don't know how to correctly take their medications, if they take the wrong dose, if they take their medications at the wrong time; that can ultimately lead to a re-hospitalization. So, medication management is huge. There's also a huge focus on home safety and safety within the community. So, as an example, we want to make sure that all of the exits are not blocked. We want to make sure that the patients have at least two ways to get out of their home in case, you know, let's say there was a fire.

We work to tap them into different resources within their community and really any other forms of support that we can help them find. Now transition support services don't usually last forever. So, really our long-term goal is to help them reach their optimal level of both health and wellness and regardless of what it is, whatever is important to that client, is also important to us.

Host: Yeah. And I'm wondering if you can tell more, you mentioned earlier the transitional case management. And what does that mean exactly? And what does it mean to be high risk?

Laura: So, with transitional case management, I had mentioned earlier that we actively start following them when they discharge home. However, transition case management really starts when the patient is admitted. My TSP case managers attend all of the weekly interdisciplinary team meetings. So, they're listening out for what we kind of call red flags, things that would make the client appropriate for TSP case management services. And the TSP case managers, they have a lot of communication with the team, be it the primary nurse, the doctor, the case manager, one of the therapists. And so that team will kind of work together to determine if the client, the patient at the time, we call them clients once we enroll them, in our services. So, with that communication, that will trigger, usually it's the inpatient case manager, or let's say we also get referrals from some of our day programs as well, but that will trigger the referring case manager to enter an order. And I'll talk a little bit about what that order might look like. So, before the patient goes home, one of the things that my case managers do is go to the room and meet with the client and meet with a family one-on-one.

Most of our communication once they go home is telephonic. So, if we can meet them face to face, if we can explain our program, it can really help us to build rapport and loyalty and trust. So, you had asked about high risk. So, I kind of group it into really two primary categories. The first is medical concerns. So, if there's a medical concern that we know is going to continue after they discharge, that's going to probably result in an order for TSP case management. Next would be any type of financial or psycho-social concern that could impact the medical outcome. So, really anything that could lead to a rehospitalization.

So, let me just give you a couple of examples that might make it a little bit clearer. Anyone who is going home on a ventilator or who might have an open airway, that would be an automatic referral to TSP case management. Anyone with a complex wound, any patient, patient discharging in a disorder of consciousness state, that would be an automatic referral.

Anyone with cardiac issues. Let's say there's been a recent fall, or if there's just overall a lack of family or community support. Those are just a few examples. And I believe that we have about 28 different concerns that can be identified that would lead to a referral to TSP case management. So, the TSP case manager will talk to the client and caregiver and they will identify who the primary contact will be.

So, it could be either the client or the caregiver, or it could be both sometimes. And the TSP case managers will either call them the day of discharge or the day after discharge. So, we want to connect immediately and they will have at least a minimum of a weekly phone call. And I want to use that loosely because when patients go home, we honestly, we can talk to them maybe five, 10 times a day, especially in the beginning, because they have a lot of questions. They have a lot of concerns and you know, sometimes things just pop up that they weren't expecting. And with most of our clients, we'll follow them for approximately 60 days post-discharge. Of course there is a really strong medical focus.

So, we're going to look at any medical concerns, whether they were concerns while the patient was at Shepard or maybe they're new concerns, any complications that they might be having. And we do all of this through lots and lots of reeducation. My case managers also have a script that they work off of, and really we're looking kind of head to toe it all body systems, psychosocial concerns, financial concerns, but we place a special emphasis on common complications or concerns that might lead to a rehospitalization for that particular person.

Now the questions that we ask are open-ended. We want to gather as much information as we can. So, an example might be tell me about how your bladder program is going. Instead of just saying, are you doing your ICs correctly? Because they might think they're doing them correctly, but maybe they're really not.

So, for our spinal cord injury population, the leading cause of rehospitalization is urinary tract infections. So, we're going to inquire about their bladder program. We're going to ensure that they're connected with a urologist who's familiar with neurogenic bladder. We're going to ask about the amount of urine that they are outputting.

We're going to ask about the color, the characteristics of the urine, and also ensure that they have an adequate fluid intake. That's really important to help flush out the bladder. So, a few other leading causes of rehospitalization for our spinal cord injury population, is any condition related to the cardiopulmonary system.

So, that would be the heart and the lungs. So, a few examples of that could be pneumonia, deep vein thrombosis, which is a clot or autonomic dysreflexia. Now with our brain injury population, we might ask some different questions. So, we're going to inquire about the neurological status. We're going to ask specific questions about safety.

So, let's say the patient is really focused on driving. We're going to make sure that the keys are locked up and that, that client doesn't have a way to access the vehicle. We're also going to, in terms of safety, make sure that everything is safe in the home, so that patient doesn't fall.

So, for example, we might want to pull rugs up in different areas of the house. So, regardless of whether it's a client with a spinal cord injury, a brain injury or something else, we're going to tailor all of our questions to that individual. And I'm just going to give you an example of a couple of things that we would of course review with any client or caregiver.

The first would be medications. We want to make sure that our clients and caregivers number one, know what medications they're taking and they know what dose to take. They know when to take the medication and they also know when to get refills. Another example would be vital signs. So, things like blood pressure and heart rate, we want to make sure that those are within normal limits for that particular patient. We're also going to inquire about their bowel and bladder, any pre-existing medical conditions that they might have. And many other things.

Host: Yeah. And let's talk about some of the other things like the financial side.

Laura: So, we kind of talked about the medical focus. We also have a really large focus on the financial needs of the client. So, let's just say a client is uninsured. We can help find them free and low cost resources in their community. We can help them to apply for waiver applications or grants. Now these can be very time-consuming and also really complicated.

So, we can kind of help the patient navigate those, or of course the caregiver. But I really want to point out that acceptance into some of these applications and these waivers and grants is so valuable, it's worth the time, it's worth the effort because it can pay for things that insurance doesn't pay for. So, for example, it can pay for caregivers. It can pay for transportation and it can pay for home modifications just to list a few.

Host: Yeah, and I'm sure there's a big emotional component to this as well. Right?

Laura: We notice a lot of anxiety and we notice a lot of overwhelm when our clients and their family members return home. Keep in mind, they're in a different environment. They don't have the 24-7 care that they had at Shepherd. So, of course, Shepherd provides an excellent discharge plan and really prepares the patient to go home. But they have a new injury and upon discharge, the unanticipated can happen. So, just an example is let's say the home health company calls you and says they don't have staffing and they don't know when they're going to get staffing. Let's say the supplies don't arrive on time or the catheter clogs. And this is a pretty common one.

So, the TSP case managers will troubleshoot, they'll find alternatives. They'll reeducate, and they'll put our clients and caregivers at ease. And of course, finally, we can't not mention mental health. So, if a client or their caregiver, if we kind of notice something is off, we can always connect them with providers in their area, be it counselors or psychiatrists. And we can also just offer an ear to listen. And my case managers are so dedicated that they'll answer calls after hours. Because the concerns don't just end at the end of the business day. So, if an issue occurs like the catheter clogs at 9:00 PM on a Friday night, the case manager will take the call and help troubleshoot the problem.

Host: You know, Laura, this sounds like a fascinating program and really beneficial to patients, especially to avoid rehospitalization. As we wrap up here, anything else you want listeners to know about the Transition Support Program at Shepard Center?

Laura: So, not necessarily just the Transition Support Program, but I have a couple of recommendations that I think would be helpful to anyone. The first would be being a self-advocate. And being a self-advocate, just keep in mind that your medical providers are there to provide you with a service. So, when you're going to your doctors, make sure you prepare notes and questions. And if you have a question, ask. Keep a detailed and up-to-date list of all of your medications, why you take them, how much you take, et cetera. Also keep with you a list of your physicians, especially if you have multiple physicians. Have their contact information, what conditions they treat and what medications they prescribe.

Never hesitate to get a second opinion. Let's just say you don't really jive with your doctor. You can always try to find a new one. If you're having trouble paying for your medications, please tell your doctor or your provider. There can often be alternatives, or they can also help put you in touch with some financial resources. If you're a caregiver and a friend or family member offers to help, let them. You know, it could be a month from now or next week. Just keep in mind that you can't pour from an empty cup.

Host: Well, Laura, thanks so much for your time today. This is an amazing program. Really benficial to patients at Shepherd Center. Thanks for your time and you stay well.

Laura: You too, Scott. Thanks so much.

Host: And you can learn more about Shepherd Center at shepard.org. This is Picking Our Brain with Shepherd Center. I'm Scott Webb. Stay well.