Bridge Services Turns One!

What an exciting year for Sierra View Medical Center’s (SVMC) new department - Bridge Services! 2022 was a year of creation and development with a focus on preventing readmissions. Bridge Service’s two departments are aligned to address needs outside the traditional healthcare model. The Palliative Care Program serves patients with Stage 4 cancer in collaboration with SVMC’s Roger S. Good Cancer Treatment Center and Dr. Owen Kim, MD. The newly created Post-Acute Care Transitions program, better known as the PACT Program, focuses on reducing readmissions for CHF, COPD and Pneumonia patients. By addressing social, emotional and financial needs and connecting patients to programs and community-based services, our teams help patients stay healthy at home.

The PACT program had some amazing achievements in their first year! They started out slowly, defining how they would identify and manage patients. Through the development of our program, they now identify almost 100 patients per month who were admitted having CHF, COPD and/or Pneumonia. Of course not all of these identified patients are qualified to participate. The team evaluates every admitted patient to target those that have the best possible chance of success in the program. About 50% of the identified patients are from skilled nursing facilities, have extensive mental health issues, have no ability to communicate via telephone or are unable to participate at a level which would lead to success. SVMC’s Bridge Services team has created a patient engagement process and developed interventions that would address their medical and social needs as well as healthcare access issues. As patient engagement improved they started to see reductions in readmission rates for participating patients.

PACT patients are identified with a daily review of newly admitted patients. Patients meet with the department’s Engagement Specialist, Cindy Sanchez, who presents the program to the patient and/or family. Cindy also completes a basic social needs assessment to help the team create a post-discharge plan of care. “I feel honored to know that patients feel comfortable talking to me and expressing their concerns about going home. And with our process, I am able to see almost 100% of the patients identified each day,” says Cindy. The PACT Team collaborates with Care Integration and the GME Residents/Hospitalists throughout the patient’s entire admission to create a continuity of care that benefits the patient and family.

One of the primary successes of the program is the post-discharge medication reconciliation. Pharmacy Technician, Crystal Hurtado has been able to engage over 80% of those patients who discharge as a PACT patient. One to two days after discharge the team contacts the PACT patient to ensure they have received all their discharge medications, help resolve any insurance barriers, and provide additional support if needed. According to Crystal, “The medication reconciliation process helps patients feel more supported in their transition home”. During that call, the patient also speaks with the Pharmacist or the Nurse Case Manager and a basic triage is completed to confirm that patients are following the discharge plan and are not in medical distress. Many times the team is able to provide small interventions that help prevent a return to the hospital.

The essence of the PACT Program involves an interdisciplinary approach to help the patient stay healthy at home. This team approach involves support with social, emotional and financial issues, healthcare education, readmission prevention strategies and navigation to community-based programs. The PACT Program engages patients for approximately 30-45 days to ensure they continue to improve. Many times interventions are “small and simple”. “Our two most common interventions have nothing to do with medications, but with social factors that affect the wellbeing of our patients: food and electricity,” says Amy Shepard, Clinical Pharmacist. “As both of these continue to rise in expense, it is becoming more difficult for the average household to sustain, especially when poor health forces patients, or caregivers, to work less”. The team provides information about food distribution programs, and income based programs which can reduce utility bills.

“Many patients have very limited healthcare literacy, and a few minutes getting discharge instruction education is not enough to keep them on track”, says Devon Barlow-Merritt, Manager of Bridge Service and RN Case Manager for the PACT program. “One of our main goals is to provide supportive education to the patient and their family so that they start to make small improvements in lifestyle behaviors. We start with basic stop light tools, especially for CHF patients. And we encourage them to discuss changes with their PCP,” Devon explains.

Although approximately 60% of PACT patients complete the program, not everyone is ready to make lifestyle changes. But for those that do participate in the program, 30-day readmissions have reduced by 78%, which is huge strides of success. Some of this success comes from navigating patients to the right community-based program. Anthem Blue Cross and Healthnet have an extended case management program, funded by the California Advancing and Innovating initiative, better known as CalAIM. These extended case management services are for those patients who are high utilizers of acute-care services, homeless or have substance use disorders. By connecting these patients to extended services, we have many examples of incredible success. have seen a patient who sought emergency room services 36 times in the preceding twelve months, reduce their visit rate to 4 times in the six months following the referral to CalAIM Extended Case Management. A huge savings in Sierra View resources!

The Palliative Care program is now in its sixth year, having been created originally from the PRIME program. This past year the Bridge services team evaluated how they might enhance and expand this exciting service. They started by increasing the number of patients in the team’s caseload to 40 and enhancing the services provided by the team. Not only does the Palliative Care Team work with patients on an outpatient basis, but they also provide the social work and case management services needed when these patients are admitted to SVMC’s hospital. The Palliative Care team becomes very close with patients and their families, and the continuity of care across hospital services is really helpful for their recovery.

Many times it is the patient who becomes the teacher. “Working with our patients helped me see how positive someone with Stage Four cancer can be,” says Noah Camacho, RN Case Manager for Palliative Care. Noah is the newest member of the team, and has brought a lot of energy and enthusiasm to the group. “My patient wants to go to a fancy dress party, so we are working to get her to a special local event. I started working with the Foundation to help us with this endeavor”.

Lupe Fernandez, the Palliative Care Licensed Clinical Social Worker says, “Getting the news that they have cancer can really challenge the patient’s perception about life and the future. We give encouragement and provide emotional support as well as provide a variety of resources to the patient and their family. From our department’s services like symptom management and nutritional support, to the community resources they sometimes need and don’t know how to access. These can all help reduce the stress associated with a cancer diagnosis.” By enhancing the appointment process to ensure that all patients are seen timely and with increased frequency, the rate of patient contact increased by 63% and newly referred patients had their initial assessment appointment within 30 days.

Other Services Provided by the Bridge Service Department

Bridge Services is the home of other services in addition to the PACT and Palliative Care programs. These are navigational services and have positive impacts to the individual, Sierra View Medical Center and the community.

• The Sierra View partnership with Uber Central and the Porterville TransPORT program has created an opportunity to reduce the financial impact of taxi vouchers to the organization. In addition, educating patients on the use of the TransPORT vans on their own can help them obtain transportation at a price reasonable for most users.
   
• Bridge Services manages CalAIM referrals for patients with Anthem Blue Cross and Healthnet to their Extended Case Management services for high utilizers of acute-care services, homeless and those with substance use disorders.
   
• CalAIM has two new community-based programs: Medically Tailored Meals and Asthma Home Remediation which are referred by Bridge Services staff.
   
  • Medically Tailored Meals are available for all CalAIM qualified patients discharging from the hospital for up to 12 weeks, free of charge. This helps with healing and recovery from illness by using healthy food as medicine.
  • The Asthma Remediation program provides in-home evaluation and free products to support home allergen reduction. This service is free of charge to patients discharging from the hospital or who have multiple ED visits for a diagnosis of asthma.

The Bridge Services Department consists of:  Noah Camacho, BSN, RN-BC, Palliative Care RN; Lupe Fernandez, LCSW, MSW, Palliative Care Social Worker; Amy Shepard, PharmD; Crystal Hurtado, Pharmacy Technician; Cindy Sanchez, Engagement Specialist; Tiffany Lu, Registered Dietitian;
Devon Barlow-Merritt, MHL, BSN, RN, CCM, RN Case Manager for the PACT Program, and Manager of Bridge Services and Dr. Owen Kim, Medical Director for the Palliative Care Program. 

A round applause to this team for making this program a success!