By Taylor Sisk
As Jean Matthews tells it, Jeneil Parker had developed a reputation at Vidant Roanoke-Chowan Hospital of being “quite the challenging person.”
Matthews, nurse case manager with the hospital’s Community Connections Program, said Parker was dissatisfied with everything related to her health care. Many regarded her as a bona fide pain in the rear.
Parker, a retired English teacher from Murfreesboro, owns up to that. She acknowledged she could be a “witch with a ‘b.’”
Parker recounts being a “frequent flyer” in the emergency department, and lots of staff people knew who she was. When Matthews met her, Parker had made at least 10 visits to the ED in the prior seven months, related to some 23 chronic diseases or disorders.
Parker has a history of congestive heart failure, chronic kidney disease, hypertension, diabetes, asthma, orthopedic issues with her back and knees, frequent urinary tract infections, and has had several behavioral health diagnoses.
She was a prime candidate for the Community Connections Program.
In 2013, the hospital received $360,000 from the Kate B. Reynolds Charitable Trust to launch Community Connections, an initiative to provide frequent visitors to the emergency department with coordinated care and intensive case management.
The results thus far have been encouraging:
Among the 23 patients who participated in the program a full year, there’s been a 65 percent decrease in ED visits compared with the prior year and a 35 percent decrease in inpatient admissions. Those participants meanwhile made improvements in their hypertension and diabetes. They’re now seeing their primary care providers more frequently, with no missed appointments among them.
A bridge to services
“Your emergency room is a mirror of what’s happening in your community,” said Matthews.[pullquote_left]Did you know NC Health News is a non-profit? Last year, a third of our funding came from readers. Please consider a donation today![/pullquote_left]Vidant Roanoke-Chowan Hospital is in Ahoskie, in northeastern North Carolina, about 100 miles from the coast. What’s happening there, health-care wise, is similar to what most every rural, underserved community in the country experiences: high rates of diabetes, hypertension, obesity and behavioral health issues.
Ahoskie is Hertford County’s largest town, with a population of about 5,000. Like other rural areas, the region has had trouble recruiting doctors. Poverty is prevalent; transportation is an issue for many.
A lot has to be done with very little.
The objective of the Community Connections Program is to transition the ED from being an island in the health care system to becoming a bridge to services and supports. It employs the medical home model of care.
A medical home model is a philosophy of primary care that’s patient-centered, comprehensive, team-based, coordinated and accessible. Providers forge relationships with patients, and treat them with “respect, dignity and compassion.”
Community Connections strives to better use community-based resources – such as Hertford Health Access, a program in which local physicians provide free care to low-income, uninsured residents of Hertford and Bertie counties – and better equip participants to self-manage and improve their outcomes.
Who will benefit?
Matthews, a nurse who grew up on a farm in adjacent Bertie County, was recruited out of semi-retirement to serve as the program’s case manager.
She examines the rolls of frequent ED patients, determines who’s most likely to benefit and what they need most. Each participant is assigned a score to rate how prepared they are to begin self-managing their care.
Then Matthews formulates a plan, and begins making connections with needed services, assessing medications, setting up telehealth assistance, providing some basic health education, making home visits – whatever that patient requires.
Most of the people she assists had come through the ED doors 12 to 15, some as many as 40, times the year prior to entering the program. Though most had primary care providers, the ED had become their default destination. Most had multiple diagnoses; about three-quarters, Matthews estimates, had a behavioral health diagnosis.
Most patients are on Medicaid; many receive both Medicaid and Medicare. The majority are from Hertford County, with others coming in from Bertie, Gates and Northampton counties.
Matthews regularly reassesses participants’ responses to their plan of care and shifts in their health status, and revises accordingly.
“Not much gets past me,” said Parker, known more commonly as Ms. Jeneil, during a recent visit with Matthews. She’s always been vocal in expressing how she feels about her care; her options for providers were dwindling.
Prior to enrolling in the Community Connections Program, she’d had a spat with her primary care provider. “He said, ‘Oh, your legs look cute today,’” said Parker, who has lymphedema, which causes her legs to swell. “I took my cute legs [out of there].”
When Matthews met her in the emergency room, Parker “was just frustrated with everything – her primary care provider that wasn’t really working out for her, her specialty care – everything was just a frustration,” Matthews said. “She’d probably reached rock bottom.”
“She was facing knee-replacement surgery,” she said, “and I thought, ‘Oh, my goodness; Ms. Jeneil and knee surgery. What are we going to do?’”
Sometime back, Matthews said, Parker had “fired” the Roanoke Chowan Community Health Center after yet another run-in with a provider. But Matthews advocated for her. She told the clinic’s chief medical officer, Colin Jones, that Parker now felt she was being heard and respected, and was prepared to mend her ways.
Jones agreed to take Parker himself.
“I told her,” Matthews said, “‘This is your last chance. Our primary care providers are limited here.’”
“She told me that I’d better behave myself,” Parker recalled, “good naturedly, with a smile and tenderness.”
Matthews sees her primary responsibility as forging relationships and trust; that allows her to speak frankly to her patients.
Parker was nervous before her first appointment with Jones. She called Matthews that morning and said, “I haven’t slept in two days and I feel like I’m going to throw up.”
Today, Matthews said, Ms. Jeneil and Dr. Jones have “become a partnership.” She’s now receiving more comprehensive, coordinated care; her heart condition and lymphedema have improved; and she’s more active.
Moreover: “Ms. Jeneil has turned her reputation around in the hospital. ‘They’re beginning to see you as a good guy,’” she says to Parker, with a smile.
“The best thing of all is that no matter what type of encounter I have with Nurse Jean,” Parker said, “I always feel better.”
The art of nursing
The Community Connections Program grew out of a broader initiative to reduce the cost of Medicaid services in Hertford County. Representatives from the hospital, the community health center, the Community Care Plan of Eastern Carolina and others formed a work group with reduction of ED visits one of the main objectives.
“We had some good outcomes from that,” said Sue Lassiter, the hospital’s president, “so we decided to look beyond the Medicaid population, took the concepts that were successful,” and asked Kate B. Reynolds for funding.
Lassiter considers what Matthews provides to be less about the science of nursing and more about the art.
It’s about “really understanding, to a deep level, what that patient’s needs are,” she said, and having the depth of knowledge of the community necessary to connect to the resources that will assist in self-management.
Mitchell has 86 clients, 45 in her active caseload and the rest in “surveillance,” meaning they’ve gone at least 90 days without an ED visit.
Ahoskie resident Cadarius Mitchell, 27, is in the surveillance category.
Mitchell has asthma, hypertension and diabetes. Matthews connected him with Terry Koch, a diabetic educator, and enrolled him in Vidant’s telehealth program.
Matthews and Koch talk with Cadarius and his mother, Vickie, about diabetes prevention. Vickie Mitchell said they explain things in a way she can understand, “and I appreciate that.”
The Mitchells don’t own a car. Cadarius’ primary care provider is in Aulander, about 12 miles from home, his endocrinologist is in Greenville, his pulmonologist in Suffolk. The Kate B. Reynolds grant provides Matthews with funding for transportation: The Mitchells receive gas vouchers to give to a neighbor to drive them to their appointments.
“I always know that Cadarius is going to follow through,” Mitchell said. “We certainly have improved his health outcome, and hopefully his long-term outcome, by helping him manage his diabetes and hypertension wisely.
“We have a relationship, a trust,” she said.
Jeneil Parker turns 69 on June 9, a day after she’s scheduled to receive her second new knee.
“This lady is amazing,” she says today of Matthews. “What she’s done for me in a short amount of time …”
“I wasn’t the one who made the difference,” Matthews countered, “but I have helped her navigate the system to find somebody who helps her make the difference.”
Parker and Matthews first connected last summer; she’s now gone 10 months with no ED visits.
“We’re allowing [people] to be partners in their own health, to self-mange and to get that primary care they need,” Matthews said. “It’s a challenge, because there’s a mindset in our community that the ED is the place to be.”
The goal now, Lassiter said, is to improve the coordination of care in all disciplines and thereby reduce the number of people who turn to the ED in the first place.
“I truly believe that every legislator needs to come to an emergency room and spend time and see what the true picture of health care is in North Carolina,” Matthews said. “That’s where you see the picture of the good and the bad.
“We have lots of good things going on.”[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]