I haven’t been as good at keeping up with this blog as I had originally hoped. But, I think that in someways that is a good thing. I’ve been really wrapped up in working at the hospital and my second project is well underway.
This past week I was introduced more fully to the program I am going to be working with for the last couple of weeks. The Chronic Illness Demonstration Project that is grant funded by the New York State Department of Health.
This project is more formally known as Hospital to Home and is well underway. It is a spin off of a pilot program that began at Bellevue Hospital in Manhattan. Bellevue is spear heading the project but, working closely with Woodhull and Elmhurst Hospital (in Queens).
While the program does span three very large boroughs, it is an all encompassing project. Each hospital’s branch of the program is organized and coordinated the same way and works closely with the executive board that oversees the project.
Last week I attended several interesting training sessions for Community Based Care Managers who work closely with social workers and the patients involved in the program. The patients admitted to the program are the hospitals’ biggest customers, they are high medicare users or fee for service medicare users.
The purpose of the program is to help these patients with whatever they need in order to turn dependence on the hospital for care into dependence upon themselves and their own capabilities.
Accessibility to all kinds of services is a key component to this program and we had the privilege of hearing from one of the pilot program’s participants named Mr. T (for patient confidentiality reasons, I think it is most appropriate to use this abbreviation). Mr. T suffers from Chronic Rheumatoid Arthritis and the battle is day in and day out. However, one of his biggest problems was getting to appointments initially because it would be too painful for him to walk to the bus stop and by the time he made it he would have missed the bus and all following appointments. So, the team assigned to him worked to get him ambulatory service and now he never misses an appointment and for that his ER visits and admissions to the hospital are significantly lower.
This program is a really impressive and innovative method of care. It is also an important perspective on how the health care system can provide for it’s patients and presents a better way for patients to manage their care.