Clinic Helps Patients Safely Transition Out of Hospital

June 26, 2019
By: NHRMC
NHRMCTransitionalCareTeam for CL
Huberta Sasser had lost her job and her health insurance when she went to the emergency room in April at New Hanover Regional Medical Center. She was diagnosed with congestive heart failure.

She spent a week in the hospital, and was released with medication and instructions to watch her fluid intake. Her care team knew she needed follow-up care.

While Sasser was waiting for her insurance to kick in at her new job, she became a patient of NHRMC’s Transitional Care Clinic.

NHRMC started the clinic for patients who are leaving the hospital and could fall into what Dr. Nicole Charkoudian calls a “care gap.”

They may be people who don’t have a primary care physician or have lost insurance, or who come from outside the area. There are some patients who have never been to a doctor or patients who find it difficult to get a quick appointment with a provider. This puts them at risk.

Patients who need prompt follow-up treatment after being released and don’t get it are more likely to get sicker, have complications and may need to be readmitted to the hospital.

The clinic provides patients with care within a week of their release, and may continue seeing them for several weeks after that. The clinic uses a team approach to seeing patients. In addition to Dr. Charkoudian, who acts as the clinic’s medical director, the team includes a pharmacist, a case manager, a medical assistant and community paramedics.

When Sasser visited the clinic, the team focused on managing her congestive heart failure, making sure she didn’t have to return to the hospital. The clinic’s pharmacist reviewed all of Sasser’s medications and filled out applications for her so she could get them at a reduced rate. Her case worker called her at least once a week to check on her.

“From the moment I got there I knew I was in good hands,” Sasser said. “You form a relationship with people. It has been a blessing to have a place I can come and not have to worry.”

When the clinic opened in December, it initially focused on patients who were treated in the hospital for congestive heart failure or Chronic Obstructive Pulmonary Disease (COPD), but now it includes all diagnoses from the hospital.

The clinic is open three days a week at 1725 New Hanover Medical Park Drive.
Categories: Patient Stories

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