Bringing patient care to the doorsteps of rural communities

If you’re a patient living on the outskirts of the county, then visiting the doctor, picking up medication from the pharmacy, and attending follow-up appointments after a hospitalization can be time-consuming. The Rural Health Discharge Program is making a difference by treating patients in their homes and saving them valued time.

Founded in June 2023, The Rural Health Discharge Program is a collaborative effort between Sharp Grossmont Hospital, the Grossmont Healthcare District, the County of San Diego and CalFIRE/San Diego County Fire. The program’s goal is to prevent people who were treated at Sharp Grossmont Hospital but live far away from having to return to the hospital for the same issue. Sometimes, these individuals are unable to access transportation or care after their discharge.

“Every person deserves to have care, and we go see them if they want us to come,” says Rose Turner, director of Integrated Care Management at Sharp Grossmont Hospital.

Care is provided by a public health nurse and fire captain paramedic to ensure the individual is doing well after leaving the hospital. Often, people need to go to a federally funded clinic, which can take up to six weeks to get an appointment scheduled, for such post-hospital services. What’s more, some people who need follow-up care go to the emergency room, where they hope to be seen almost instantly; however, that may not be the ideal setting to address their needs.

How the program works

The Rural Health Discharge Program is free and open to anyone. The simple requirements are to have been discharged from Sharp Grossmont Hospital and to reside in Boulevard, Campo, Descanso, Guatay, Jacumba, Pine Valley, Potrero or Tecate.

Case managers at Sharp Grossmont determine who is eligible. Once enrolled, a public health nurse and fire captain paramedic visit the person in the hospital to introduce themselves, explain the program and make an appointment to attend to their needs once home. Each individual receives care for at least 30 days via phone or in person.

Once the team of two arrives at a person’s home, they do a thorough, individualized check-up. and leave kits to help them manage their chronic illnesses. These free kits address conditions such as heart failure, stroke, diabetes, chronic obstructive pulmonary disease and (COPD), and contain various things, including pill boxes, scales, mirrors and education materials.

The nurse sets up everything at the person’s house in clear view and does medication reconciliation, the process of identifying an accurate list of every medication the person is taking. They provide instructions in a simple, easy-to-understand manner, ensuring the person understands how to care for themselves.

The fire captain paramedic can also install or examine smoke alarms, fire extinguishers and LED nightlights, and address other needs, including fire mitigation. For instance, if they notice that weeds or grass surrounding the home are becoming a hazard, they trim it to create a safer path. For those who are eligible, they can also schedule a service to clear the debris.

Additionally, by working with the person’s insurance, the team can arrange for a 90-day supply of medication to be provided. Receiving 90 days’ worth of medication saves the program’s participants a trip to the pharmacy that could take up to two hours.

Participants are also informed of county resources that may be available to them. This can include organizations that provide everything from dental, medical and mental health care to food, clothing, furniture, social support, substance abuse treatment and transportation.

Connection beyond health care

According to Kaila Domingo, one of three public health nurses with the program, if there is one word to describe the Rural Health Discharge Program, it would be “caring.” The program tailors its services to each patient's unique needs, with the team showing attentiveness to every aspect of their care.

Apart from receiving health care, some patients even express interest in playing a board game or taking their dog for a walk. The team members happily fulfill these requests, ensuring their needs are met.

“Patient follow-up care has improved since the program launched because patients realize that there are people who care about them, who want to go out of the city and all the way to where they live,” says Domingo. “When you show up to their house and show them that you're there to help them, they get motivated to start taking better care of themselves.”

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