At St. Mary Medical Center, care doesn’t just stop when a patient is released from the hospital. Through the Quality Care Coordination program, patients who are at risk for relapses and additional trips back to the hospital are assigned to a Care Team. Their “Care Navigator” works with the medical team to ensure that the patient has what they need to stay healthy. Dealing with social needs, like making sure the patient has good food, a safe home, or even a dog-sitter, is an important step in a patient's overall care.
“Patients need advocates and they’ve chosen us to help,” said Marcie Fillippo, nurse case manager at St. Mary Medical Center. “Of course we’re going to help. We’re here to advocate for their care.”
The navigator program has been in place at St. Mary Medical Center for six years and has had great success focusing care on patients’ needs beyond the clinical. St. Mary Medical Center’s program model is patient- and disease-diagnosis focused, rather than floor focused. This means that patients can stay under the extended care of the same navigator who understands their needs.
“I think our program has been very successful in how we are structured,” said Kim Sgouroudis, administrative director of Patient Care Services for St. Mary Medical Center. “I think it does give those patients who do come back to the hospital consistency. You have somebody you can trust, so patients are more open.”
From nurses to social workers to operational assistants, the seven different navigator teams work with local organizations like United Way, Lions Club and local food banks to make sure their patients have what they need when leaving the hospital. This often includes going above and beyond to find a solution to tricky problems. Thinking outside the box and going that extra mile is what St. Mary Medical Center does best, said Sgouroudis and her team.
One recent success story centered on finding healthy food for a patient who was legally blind. After speaking with a manager at a local Strack & Van Til, the care navigator found that the grocery delivery system the store offered was online through Instacart, which would have been difficult for their patient to use. Strack’s worked with the hospital to process an order, then graciously sent two employees to the patient’s home to deliver the groceries. While there, the employees saw indications that the patient might be in distress, so the store contacted the navigator, who was then able to send out a community paramedic to provide care for the patient in the home.
“That is proof that you can save a life when you go the extra mile,” said Sgouroudis. “For the 32 people on our team, I think going the extra mile is just their day-to-day.”
For St. Mary Medical Center, educating the community and surrounding centers and agencies is important as well. If a consistent health issue is noticed, they will volunteer their time and expertise to train others in procedures and what to look for to address typical health issues. It’s one more way that St. Mary Medical Center can be proactive in making sure patients remain healthy and safe in their homes.
With the aid of grants, such as one from the John W. Anderson Foundation Grant, the hospital has been able to help patients with the cost of medications. Ensuring that patients have their medications is a priority in keeping them healthy. For patients who have no insurance, or insurance that only covers a small cost of medications, this can be a life-saving option.
Along with medication assistance, St. Mary Medical Center has allocated grant monies toward transportation assistance. This allows patients to receive transportation to and from appointments, which is important for continued health. The transportation is completely free to the patient thanks to this grant funding, which helps to ease the stress for those who do not have the ability or funds to provide their own transportation.
The Quality Care Coordination program at St. Mary Medical Center is a necessary program that continues to see success. The navigators and teams are always ready to roll up their sleeves and go to bat for their patients. It is important to them that their patients have what they need to ensure their health and well-being.
“The more proactive we can be on behalf of our patients, the less time they hopefully will spend in the hospital,” said Chris Sheid, director for Marketing and Community Relations, St. Mary Medical Center. “That’s ultimately our goal and I know it’s our patients’ goal, as well.”