CHI St. Vincent Health participates in the Bundled Payment for Care Improvement (BPCI) program, a Center for Medicare and Medicaid Services-approved program that incorporates financial and performance accountability for patient care. The health coaches involved in this program have been instrumental in touching people’s lives and making a difference in their recoveries. To provide just one example, health coaches Labray Merkel and Natalie Martin were able to proactively change what could have been a devastating outcome for a patient.
Both health coaches personally interview patients who have joint replacement surgery. During their rounding they met Judith, a sweet, elderly patient who lived 60 miles from Little Rock. She was having a complicated surgery, and they learned that she had some barriers to care. The original plan was for Judith to transfer to a skilled nursing facility after discharge, but the plan changed and she was discharged to her home with a plan for follow-up contact. Labray was concerned about Judith and contacted her immediately. Judith was tearful on the phone and said she was not doing well.
With help from a social worker, Labray and Natalie found solutions for Judith’s barriers to care, which included no family support and a husband who is bound to a wheelchair. The team found that Judith was a candidate for home health services. They obtained orders for home health care and arranged a home care visit for the very next day.
However, when Natalie made a scheduled follow up call 48 hours after Judith’s discharge, she learned that Judith had become weaker and was unable to take care of herself at all. Natalie told Judith to call 911 and notified the on-call surgeon at St. Vincent.
Judith went to a hospital closer to her home, where the initial work-up revealed that she had developed a urinary tract infection and required two units of blood. Once Judith was out of immediate danger, the health coaches made arrangements for her to transfer back to CHI St. Vincent so her surgeon could oversee her care.
When Labray and Natalie shared this story, I knew it was God in action. You see, I had been the first health coach for the BPCI program and had loved the work. When I was offered a promotion to a supervisory role, I was hesitant to leave the bedside, and I prayed for guidance in choosing the path that God wanted me to travel. When I decided to accept the new role, I prayed that God would allow me to find the right people to continue the program.
Proverbs 3:5-6 says, “Trust in the Lord with all thine heart; and lean not unto thine own understanding.”
When the team told me the story of Judith, tears came to my eyes. I realized that I had trusted in the Lord the day I decided to change my path in the program. By doing so, I grew in my faith and watched others grow in theirs.