July 7, 2020

“Saving Grace”: Community Partnership Helps Patient Return Home

In the Spring of 2018, Steve Frost had an epileptic seizure while driving. He went to UCHealth Memorial Hospital Central, Photo of Steve Frostspent three months there, got out, had another seizure a month later and was back in the hospital for three more months. During his second stay, squatters broke into his modest, one bedroom mobile home in Fountain. When a social worker checked to make sure the residence was safe, she found disaster. Frost, who was medically fit to leave the hospital, had nowhere to go.

Frost has had pancreatic cancer, multiple fractures in his back, and severe epileptic seizures. He didn’t want to go to a skilled nursing facility upon his release from the hospital. With a little help from the Hospital to Home (H2H) program, he’s able to be home.

Mandi Strantz, The Independence Center’s (The IC) transition coordinator for the H2H program, worked with another organization in Colorado Springs to rebuild a shower in Frost’s home, through a long-term Medicaid waiver, making his ability to shower on his own possible. The lC also sends helpers who go to the grocery store for Frost and prepare meals that he is able to heat up.

“They were just a saving grace sent by God, literally,” Frost said. “Mandi, she was an angel when she came in the room that
morning because I didn’t know what I was going to do. They were telling me that I couldn’t come home because I couldn’t
take care of myself.’’

Two agencies come together to create Hospital to Home program

Strantz’s position is paid for by the partnership with UCHealth, through a $120,000 award from the Memorial Hospital Foundation. Services include meals in the home, transportation, setting up home health care, occupational therapy, physical therapy, respiratory therapy, setting up homemaking services like housekeeping and grocery pickup, receiving and setting up durable medical equipment, and helping with medication delivery and funding. Social workers call on The IC when a patient is medically ready to go home, but can’t because of living conditions. The IC provides case management and resources to improve living conditions and help keep patients out of the hospital.

“This is a clever program and shows how we’re seeking ways to help people and reduce costs at the same time,’’ said Joe Foecking, director of the inpatient rehabilitation care unit at Memorial Hospital Central. Foecking also serves as chairman of the board of The IC. He presented the pilot program to Memorial leaders who recognized how it would improve patients’ lives. “We are freeing up resources for other people in our community who are acutely ill and need a hospital bed, and we are accommodating individuals in the most humanitarian way,” Foecking said.

Transitioning people from the hospital to their home Patricia Yeager, CEO of The Independence Center, said, “There’s a lot of research around ‘Why doesn’t health care work?’ and usually it’s social determinants of health, like housing, having a job, having transportation, food, security and all of those kinds of things. So that’s our specialty, the social determinants of health.’’

Strantz said the patients that she helps are often referred to her by discharge planners who work at the hospital. “If there are barriers to a safe discharge, then they’ll reach out to me and we see if we are able to help out. In Steve’s case, the planner talked to him and then reached out to me,’’ Strantz said.

Low-cost assistance after hospitalization

Frost said the program has made a huge difference in his life. “They got me home. Now that I can’t drive or anything, I’m dependent on them,’’ he said. “So, there’s always some paperwork to fill out, or if I need to go somewhere or something, Mandi makes it happen.’’

Frost has had hernia surgery and gallbladder removal surgery in the past year, but he has not been readmitted to the hospital after each event because of the low-cost assistance provided through H2H and other community programs.

Through this important partnership, dozens of people will be helped – people like Frost who, like anyone else, just wants to be home.

For more information on the H2H program, call The Independence Center at 719-471-8181.

Article adapted with permission from “Breaking down barriers to a safe hospital discharge through a new community partnership and Hospital to Home program,” written by Erin Emery and originally published at UCHealth Today. Read the original article at bit.ly/h2h_uchealth.