2010 Nursing ANNUAL v4d - PinnacleHealth

“The Book of James” by Altair Dasilva, RNCommitmentto the CommunityPinnacleHealth nurses are committedto serve the community by buildingrelationships that promote nursingprofessional development and improvepatient outcomes.Hospital to Home ProgramA collaborative effort between CTU and theHeart Failure Center is reducing readmissionrates for heart failure patients through theHospital to Home program. The programis a national quality initiative led by theAmerican College of Cardiology to improvethe transition from inpatient to outpatientstatus for individuals hospitalized withcardiovascular disease. CTU developeda unit-based Heart Failure Committee withthe following members: Elizabeth Welch,Keatha Gardner, Tina Dietman, KatieScofield, Patty Novak and Trish Bennett.The group has implemented several processchanges to provide a seamless transitionfor patients to home. Discharge medicationprescriptions are faxed to the patient’spharmacy and follow-up appointments arescheduled prior to discharge. An OutcomesManager is also making follow-up phonecalls within seven days after discharge. Asa result of this collaboration, there has beenan increase in referrals to the PinnacleHealthHeart Failure Clinic.Congregational Health NetworkPinnacleHealth has always had a strongcommitment to parish nursing. Aninterdisciplinary committee was formedled by Barbara Terry, RN, VP for MissionEffectiveness, to develop a CongregationalHealth Network. The network would linkexisting hospital and congregationalresources to assist patients in navigating thehealth system and accessing care. This typeof network could decrease inappropriateutilization of services such as unnecessaryED visits and potentially decrease healthcare costs. It could also strengthencommunication between the broadercommunity and the healthcare system.The Congregational Health Network modelincludes the role of a navigator that isassigned to work with a congregation.The navigator is a member of the PHShealth care team who is responsible fordeveloping a working relationship with anassigned congregation. The navigator willassist the congregation with utilizingresources, problem solving health careissues, and navigating the healthcaresystem. Kelly Lesh, RN, WomanCareNurse Educator, and Theresa Sellers, NM,CTO, are navigators for the Wesley UnionAME Zion Church and hosted a health fairto promote heart healthy behaviors.The congregation has many Puerto Ricanparishioners. Elisabeth Perez, PatientRepresentative, and Hilda Rivera, RN,CDE, Diabetic Educator, have assistedKelly and Theresa with this congregationbecause of their fluency in Spanish. SharonKelly, LI, and Maria Chianos, OutcomesManagement, are navigators forPresbyterian Homes.17