Avera Medical Minute: Avera Health Care Transitions - KSFY News - Sioux Falls, SD News, Weather, Sports

Avera Medical Minute: Avera Health Care Transitions

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Plankinton's Sally Erdahl gets a visit at her home from Avera Queen of Peace Home Health Care Nurse Jenna Linke as part of the Care Transitions Program. Plankinton's Sally Erdahl gets a visit at her home from Avera Queen of Peace Home Health Care Nurse Jenna Linke as part of the Care Transitions Program.

Most people don't want to wind-up in the hospital, yet patients who have congestive heart failure, pneumonia, or COPD are more likely to have to go back in to the hospital within a month of being discharged. Most of the time that happens because they didn't properly follow their doctor's orders. Nancy Naeve Brown has more on program offered by Avera Health that is trying to change that trend.

When Avera Queen of Peace Home Health Care Registered Nurse Jenna Linke paid a visit to Sally Erdahl in her Plankinton home the day after Sally was discharged from the Avera Heart Hospital it was just what the doctor ordered.  Sally has a faulty valve which has lead to congestive heart failure plus she has really bad acid reflux.

"They sent me home and said lose weight, lose weight lose weight. I've lost 50 pounds, but it took two years. The dietitians at Avera Queen of Peace have really been helpful." Sally said.

Because Sally suffers from congestive heart failure, she qualified to take part in Avera Health's Care Transitions; "From hospital to home" program.  It's a month long follow-up with your local Avera hospital that helps prevent patients from going back in to the hospital. A Home Health nurse makes an initial visit within 2 days of the patient's discharge. It also includes weekly calls.  Registered Nurse Nathel Cody in Avera Queen of Peace's Case Management Department checks on Sally frequently to make sure everything is going well.

"Previously we would dismiss the patients, give them their instructions and wish them good luck. Now we go in to their home for a period of 30 days to be sure they adjust to home environment from the hospital." Dr. Herb Saloum said. He is the Medical Director of Avera Tri-State Affiliates and Board Chair for Avera Health. 

Each patient in the Care Transitions program is sent home with a kit. It includes the information they need that pertains to their illness, a pill container to keep track of their medications and a scale.

"When a patient gets into trouble with congestive heart failure it's because too much weight gain from fluid. So if they've gained a couple of pounds in 2 days it can mean extra fluid and that can be hard on their hearts," Melonnie Gregerson, Director of Case Management and Social Services at Avera Queen of Peace in Mitchell, said.

"Right now we are dealing with 4 major diagnoses; congestive heart failure, acute myocardial infarction, pneumonia and COPD. Those are the 4 that are responsible for the most re-admissions, "Dr. Saloum said.

In its first year, statistics are proving the program works. 22% of patients like Sally with congestive heart failure end up back in the hospital within 30 days of being released.  The Care Transitions program reduced that number to 5%.

"It's made a significant impact," Dr. Saloum said.
Even though Sally lives on her own, through Avera Health's Care Transitions program, she isn't alone in her recovery which, best of all, is at home and not at the hospital.

Care Transitions started as an Avera Pilot program in June 2010 with patients from Avera McKennan and the Avera Heart Hospital who live within a 40 mile radius of Sioux Falls. It's now expanded throughout the Avera System.


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