Regardless of how well they are managed, complex medical conditions such
as congestive heart failure, diabetes and chronic obstructive pulmonary
disease occasionally flare up-- landing many in the hospital for intensive
treatment. Once symptoms are under control, patients leave the hospital
with a plan of care that may include follow-up appointments, dietary restrictions,
a prescription for additional exercise or other lifestyle changes, and
new medications, treatments and therapies.
For the patient with a strong support system, following a plan of care
is less difficult. But for those without resources, the road to better
health means trying to navigate around barrier after barrier.
Unfortunately, these patients frequently end up back in the hospital very
quickly—sometimes in a matter of weeks or even days. These re-hospitalizations
create increased anxiety, unexpected costs and added inconvenience for
the patient and their support system.
Given our aging society, and the many demands for limited health care dollars,
finding ways to reduce readmissions is more critical than ever. At FMH,
social workers are playing a key role in a variety of programs aimed at
decreasing readmissions by easing the transition between hospital and
home for patients.
Some studies estimate that 50-60% of relapses following hospitalizations
are due to social issues. Patients with a poor understanding of their
conditions may not understand the importance of making those recommended
lifestyle changes. A language barrier may interfere with their comprehension
of discharge instructions. A lack of insurance or limited income may get
in the way of their scheduling of follow-up appointments, or filling prescriptions.
The absence of transportation or child care can make it difficult to actually
make it to their appointments.
One way FMH is trying to address these issues is by embedding social workers
in the Emergency Room. After stabilizing the patient, if the ER staff
determines they need a more complex intervention, they get a social worker
like Nicole Wetzel involved to serve as the coordinator of a more long
term plan of care.
Wetzel and others help connect these patients with the care they need;
often starting with a visit or two to the hospital’s own free CARE
Clinic. While the clinic’s nurses focus on teaching these patients
about their diseases—how to recognize symptoms, and the importance
of adherence to diet, exercise and medication regimens—social workers
like Wetzel help identify community agencies and independent resources
to equip them with the tools and support they need to succeed.
“When you don’t have support, managing a chronic disease is
scary and intimidating,” said Wetzel. “Our job is to see patients
through to the next step on the road to feeling better. We’re here