Knox Community Hospital has programs to make sure patients get the care they need when they are in the hospital and after they leave.
One program for Medicare patients is called Transitional Care Management, Deborah Priest, a registered nurse who directs the hospital’s Population Health programs, told the Mount Vernon News.
“For the 30 days after the patient is discharged, we will make sure the patient is receiving all their medicines, that they are connected to Home Health if they need to be, that they receive other services such as physical therapy,” Priest said. “We are making sure that within that first 30 days, the patients don’t end up back in the hospital. We focus on meeting their needs, whatever they might be.”
Another aspect of the Population Health Department is a longer-term Chronic Care Management program if the patient still needs care beyond the 30 days.
“That’s for any Medicare patients who have two chronic diseases,” Priest said. “We’re looking for gaps in care. They may have difficulty getting prescriptions and need assistance; or maybe they need housing. We try to take care of the socio-economic needs as much as we do the medical needs.”
The hospital also encourages patients with chronic conditions to have preventive care. Doctors encouraged one patient with diabetes to get a mammogram, which led to a diagnosis of Stage 3 breast cancer, Priest said.
The hospital can also help patients stay at home rather than go to a nursing home or hospice.
“We had two patients we lost in August, and they were home when they passed, which was their goal,” Priest said.
The hospital also offers a wellness program for Medicare patients to help them avoid having to come into the hospital in the first place.
“This is just a beginning step to find out what their goals are in the next five to 10 years,” said Priest.
The best way to access the Population Health services is through your primary care provider, Priest said. If you don’t have one, Knox Community Hospital has a primary care department.
You can also get a referral through your home health care agency.
