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Program Aims To Keep Patients Out Of Hospital After Release

If you’ve ever been to the hospital, you know it can be tough to get home and then follow all the various new drug regimens or wound care instructions.

And for people who have complex medical issues, or problems such as depression, those instructions can be overwhelming. So much so in fact, that patients regularly end up right back in hospital.

Oregon Health and Science University has developed a new program to tackle this problem — with the goal of not only keeping patients healthier, but also saving money.

Readmissions are something that 54-year-old, retired TriMet driver, Julie English knows all about.

Julie English has been readmitted to the hospital three times  and now receives help from Leah Croft, a Transitional Care Nurse.

Julie English has been readmitted to the hospital three times  and now receives help from Leah Croft, a Transitional Care Nurse.

Kathryn Boyd-Batstone/OPB

She’s diabetic. She has high blood pressure and suffers from cellulitis — a skin infection that causes an itchy rash.
It’s so painful in fact, that in April, she ended up in hospital for a couple of days.

Sitting comfortably at home now, with her cats and fish tanks, she explains how she was released.

“So the pain had gone away and the redness had pretty much gone away. And there was really no blistering and I felt a lot better, the fever was gone. And so the doctor decided that you know, I was probably going to be okay. So they prescribed some antibiotic to go home with and that was kind of it.”

What about instructions for home care?

“They didn’t really say a lot in the report that I took home, as far as what I should do and stuff, I mean if the fever starts in again or that kind of thing. I don’t think they mentioned anything about the blistering or anything. So, I kind of didn’t really know what to do.”

She says she took the antibiotics she’d been prescribed. But then, her rash got really itchy and she started to scratch.

“Blistering started in probably three days after I got home.”

So, she went back to the hospital and was there for four days. Her stay was covered by  her insurance. But readmissions cost insurance companies and the government a lot of money.

As part of federal health care reform, the Centers for Medicare and Medicaid Services started reducing payments last year to hospitals that didn’t tackle the problem.

So this time, before she was released from the hospital, English was put in touch with OHSU nurse, Lea Croft.

“I met Julie, pretty close, it was the day that she was actually leaving the hospital and I had been able to identify her as someone that was most likely going to need some additional help when she got home.  She had some pretty complicated wound orders in place and a whole lot of other just kind of things that the potential for falling apart when she got home.”

Leah Croft (left) talks to Julie English (right) about the correct way to take her medicine.

Leah Croft (left) talks to Julie English (right) about the correct way to take her medicine.

Kathryn Boyd-Batstone/OPB

English says having Croft’s support made all the difference.

“Well, she’s helped me a lot with the signs and symptoms and what to do. And she accompanied me to my doctor for the first visit after I got out of the hospital. I was prescribed some lotion that was extremely expensive, like $200 and she arranged through the insurance company to have them pay for it so I could get the medication and not have to pay for it. So she’s been real helpful. And anytime I needed anything, she’s been there for me.”

Would English have bought the $200 cream herself?

“Probably not. It’s not

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