![Health care working arriving at patient's home for a home health visit](https://images.ctfassets.net/pxcfulgsd9e2/6h5tdEkf5l01NArxDhjSrl/3fdc0a2c7637ddce272e27a11ab33268/Rural_Health_Discharge_Program_HN3727_iStock_1387432869_Sized.jpg?f=top&fit=fill&fl=progressive&fm=jpg&h=786&q=85&w=1396)
Bringing patient care to the doorsteps of rural communities
For patients needing follow-up care in distant communities, the Rural Health Discharge Program brings caregivers to their homes.
Case management has always been a vital component of the health care system. During the coronavirus pandemic, the case management team, which regularly serves as a patient and family advocate, had to adapt to ensure patients could safely leave the hospital after their recovery.
As the main liaison to navigating a patient through the continuum of care between the hospital and community, case managers kept up with the increase in demand for their expertise.
“We were navigating through new waters with COVID-19 to create unique transition planning, meet specific needs and capture the changes in the patient support system,” says Lupita Mora, director of integrated care management at Sharp Chula Vista Medical Center. “There were many times when we were unable to send a patient home because their family members were also hospitalized or were in quarantine themselves. We worked with San Diego County’s temporary lodging resources to coordinate these unique discharges.”
During the pandemic, case managers had to find inventive ways to coordinate a patient’s care from a safe, social distance, not only for their own safety, but also for the safety of their friends, family and colleagues around them. Distance did not deter their commitment to their patients to deliver quality, compassionate care.
“Transition planning during a pandemic added a layer of complexity to the already demanding role,” Mora says. “One of our biggest challenges was the new visitation restrictions put in place to protect our patients and staff. Historically, we relied on family and friends to learn more about the patient and understand their baseline needs. At the same time, case managers stopped meeting with patients in their room for assessments. In order to get to know the patient, we had to transition to remote communications and build trust and rapport with our patients and their family over the phone. Building a relationship is crucial to formulate a safe and sustainable discharge plan.”
While simultaneously managing an increased caseload, case managers have gone beyond expectations to interface and work in partnership with health care workers and community partners while encouraging their patients to take an active role in their care.
“We have faced many unique situations where we had to think outside of the box to coordinate continuum of care,” says Mora. “Knowing that we take a key role in transitioning a patient out of the hospital brings a lot of pride. The pandemic has definitely made us better communicators and improved our collaboration skills with post-acute care facilities, community services, patients and their loved ones. The biggest reward of all is knowing we lead the way in transferring care safely during uncertain times and contributing to the patient’s overall wellness.”
Above all that case managers had to overcome during such a critical time, the human aspect that they contribute to a patient’s care once they are ready to safely go home makes all the difference in improving their quality of life.
The Sharp Health News Team are content authors who write and produce stories about Sharp HealthCare and its hospitals, clinics, medical groups and health plan.
Lupita Mora is a manager of acute care at Sharp Chula Vista Medical Center.
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