Making a difference: helping the whole patient through transitional care

When 86-year-old Mary McGillivray had a health scare last summer and was rushed to TMC’s Emergency Department, it wasn’t what happened in the hospital that brought her the greatest sense of relief.  It was the care she experienced – when she was home.

Mrs. McGillivray was admitted with severe abdominal pain.  After an assortment of tests, doctors determined she needed her gallbladder removed.  She underwent an operation, and anticipated going home shortly – until her heart developed atrial fibrillation.  A week later, her heart finally converted to a normal rhythm.  She received a thumbs up to head home, but had to be on oxygen – which was a whole new world for her and her husband, Edward.

“We had a lot of questions about the oxygen, and using the tank correctly.  We managed to make it through that first night, but I was a mess – and then Karen showed up,” said Mrs. McGillivray.  Karen Popp, RN, is a Transition Nurse & Care Advocate for Arizona Connected Care (AzCC), an LLC owned by primary care physicians, specialists and TMC that is Southern Arizona’s first Accountable Care Organization, or ACO.

An ACO is a network of physicians, hospitals and other health care providers who share the responsibility of caring for patients in a coordinated manner.  Mrs. McGillivray’s primary care physician, Dr. Mark Zaetta at New Pueblo Medicine, is one of the approximately 200 doctors currently in the ACO, which qualified her for the Transition Intervention Program, this specialized post-hospital care.

While at the McGillivray residence, Popp answered an assortment of questions about oxygen.  “When dealing with oxygen for the first time, there is a lot to learn.  When you compound that with being discharged from the hospital, new medications and new instructions, it’s hard for a patient to retain the education that’s been given to them at discharge.  Then, when they are ready to retain it, there’s nobody there to teach them,” she said.

That’s exactly what this program aims to do: empower these patients with education, and help them stay out of the hospital.

For Mrs. McGillivray, the knowledge she received was priceless.  “Karen told us how to do everything, showed us, and then made sure we knew how to do it.  I was so grateful to have her and her expertise.  I felt like ‘somebody knows what they’re doing, and they’re taking care of me.’  It was just marvelous,” she raved.  “Edward felt more confident taking care of me.  The visits were a lifesaver for both of us.  Without Karen, I don’t know how I would have survived,” she said.

Months later, Popp continued to follow-up.

“It was really nice to know that she cared.  With Karen, I felt like I had a partner throughout my entire recovery process.  It gives my children peace of mind that I’m being well taken care of.  And it gives me peace of mind to know that if I do have to be hospitalized in the future, I’ll get this same standard of care,” Mrs. McGillivray said.

AzCC2 002

Arizona Connected Care’s Office of Care Coordination:
Amber Jones, BSN, RN – Transition Nurse;
Karen Popp BSN, RN- Care Advocate/ Transition Nurse;
Tina Wren, MA- Care Coordinator

Through the Transition Intervention Program, patients are prioritized based on their risk of being readmitted.  “The home visit follow-up care is offered to the highest risk patients first.  If other patients ask for it, they get it.  If we are talking to a patient who is at a moderate risk for re-hospitalization during a post-hospital follow-up call, and we get the feeling that they could benefit from a home visit, we offer it to them,” said Popp.  Home visits are usually an hour or more.

“The program helps patients realize they’re more than just a number.  We’re helping them pick up where the hospital left off.  When they’re in the hospital, people are doing amazing things for them.  When they’re home, they don’t always have that safety net.  Our job is to support them even though they’re not within the hospital walls anymore,” said Popp.

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