Just over 20 years ago, a parade of ‘frequent flier’ ER patients with poorly managed chronic diseases caught the attention of nursing leadership at Louise Obici Memorial Hospital in
Suffolk. The conditions causing the most repeat ER visits at the time were diabetes and heart failure.
Many of those patients were indigent and uninsured. Many could not afford needed medications, which aggravated their conditions, causing ER visits time and again. It was a revolving door, into and out of the most expensive and least preventive form of health care. The term ‘Population Health’ was just entering the vocabulary of health care as hospital leaders devised a way to interrupt the costly and debilitating cycle of ER visits and readmissions. The hospital committed a full time nurse, Lisa Arrington, to visit patients’ homes to help manage chronic conditions, provide education on ways to stay healthier and connect them with free or reduced-price medications through pharmacy companies’ charity programs. They gave the new effort a name; the Community Health Outreach Program, or CHOP.
The program quickly outgrew Lisa Arrington. Over the next few years, it expanded to four
field nurses. In 2009, after the 2006 merger with Sentara Healthcare, CHOP began to transition away from grant funding through the Obici Foundation to a fully-supported hospital-based operation in 2012, consistent with the Sentara not-for-profit mission.
“It is a vital part of my practice for my indigent and underinsured patients,” wrote a cardiologist endorsing CHOP. “It has clearly reduced hospitalization and improved patient health…” “Our mutual patients have better medication and dietary compliance,” wrote an internal medicine physician. “The nurses have been a great help encouraging patients to keep their medical appointments.” Twenty years later, Lisa Arrington and her three colleagues are still on the road. They see patients in their homes, under bridges if necessary and on the street – whatever it takes to deliver compassionate care where patients are. They also perform home assessments to help resolve safety issues and connect patients with community resources. The panel hovers between 80 and 100 patients.
Lisa Arrington received a Sentara DAISY award in 2017 for extraordinary nursing, for driving a homeless man with congestive heart failure (CHF) to a rooming house and paying part of the rent to get him off the street in winter. DAISY awards are a national program in which patients and fellow employees can nominate nurses for above-and-beyond performance in support of patients and their families.
The list of conditions CHOP nurses monitor now includes pneumonia and sepsis after patients leave the hospital, plus chronic diseases like chronic obstructive pulmonary disease
(COPD) and hypertension, as well as the original diabetes and heart failure. They connect indigent patients with the Western Tidewater Free Clinic or the Community Health Center to establish medical homes and physician relationships. The goal is the same as 20 years ago when CHOP started – effective disease management to improve quality of life, reduce ER visits and hospital readmissions and lower the overall cost of care.
For 20 years of community-focused population health management, personal courage and creative solutions to overcome barriers to care, the CHOP program at Sentara Obici
Hospital received a ‘Health Care Heroes’ award from Inside Business magazine in February 2018.