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Tour Guides on the Road to Wellness

Transitional Care, Wellness Nurse Navigators Coordinate Care for Seniors

Thanks to provisions in the Affordable Care Act, the Center for Medicaid and Medicare Services has provided funding for an 8-year pilot program to improve cost and quality of care provided to seniors in the state of Maryland. Beginning in 2019, the Maryland Primary Care Program (MDPCP) was developed to provide primary care physicians the resources to improve care.

Transitional Care Nurse Navigators

“Navigating medical care can be daunting, frustrating and confusing for anyone, let alone a senior who has just been released from the hospital, has been given a diagnosis for a chronic disease, or is facing end-of-life decisions,” said Calvert Internal Medicine Group’s (CIMG) geriatric specialist Dr. Jonathan Lowenthal. “It is also daunting, frustrating and confusing for the family or caregivers of seniors.”

Transitional Nurse Care Navigators, in coordination with physicians, assist senior patients who have been recently discharged from a hospital stay, rehab or the emergency room.

“Anytime a patient is in the hospital or emergency room, a nurse manager will call those patients to make sure they follow up with their primary care provider. The nurse managers not only make sure patients have their medications, they review them and make sure the patient can afford them,” said Dr. Lowenthal, adding that CIMG added four full-time nurse care managers that assist the practice in caring for senior patients. Like CIMG, CalvertHealth Primary Care (CHPC) also offers similar services.

“There is a lot of information for patients to process when they are discharged,” said Transitional Care Navigator and Wellness Nurse Debra Schwenk, RN, BSN of CIMG and CHPC, who connects recently discharged patients with the sources and support they need to prevent readmission and stay healthy after they go home.

“I’m here to answer questions, to confirm that patients have been able to obtain new medications or equipment needed, and to assist with making follow up appointments,” said Schwenk.

Schwenk has found that sometimes being a caring ‘ear’ on the other side of the phone is just what a person needs following the stress of a hospital stay. Even though discharge summaries are discussed with patients before leaving the facilities, she said, patients are stressed and overwhelmed and by the time they get home much of what was told to them is forgotten or misunderstood.

Wellness Nurse Navigators

In between her work as a nurse navigator, Schwenk provides Wellness Visits which are covered yearly by Medicare.

“Some seniors are skeptical about the need for a wellness visit, but I would say that most have left the exam feeling they were glad that they kept the appointment,” said Schwenk. “These visits allow us to update charts, review any needs for immunizations and preventive tests, perform a cognitive screening and assess fall risks.”

The benefit of doing this yearly, according to Schwenk, is that if there are significant changes from the last visit, the patient, caregiver and healthcare provider have time to make adjustments to care. Appropriate decisions can be made for either further testing and/or the knowledge can be helpful in making decisions based on the patient’s needs for the future, said Schwenk.

Guiding Seniors in All Aspects of Healthcare

According to Lowenthal, in addition to nurse care managers, CIMG has a psychiatric social worker to assist patients with psychosocial stressors and dependency issues, and a community health worker who can assist patients with finding resources necessary to manage all aspects of their healthcare needs.

“We are working to provide more support to patients with managing their medications,” said Lowenthal. So far, CIMG has hired an additional 12 full-time employees who are dedicated to assisting our senior patients with health care needs.”

Whether following a hospital or emergency room visit, or rehab visit, or through an annual wellness exam, area nurse navigators assist senior patients in getting the healthcare information and resources they need.

“I’m here to help [patients] navigate any changes as they are aging, receiving new diagnoses, or during illness or recovery from an injury or surgery,” said Schwenk. “We want them to live their best life and feel valued as a person as we partner with them to meet their needs.”
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