Shepherd Center Launches New Program to Assist Patients and Families Following Discharge
ATLANTA – Shepherd Center’s new Transition Support Program is leading the hospital’s mission to improve education, guidance and support to patients and their families upon discharge with the goal of improving health outcomes and increasing customer satisfaction.
Leading the new program is Ginger Martin, M.Ed., CCC-SLP, CCM, a long-time member of Shepherd Center’s former Marcus Community Bridge Program, which ended in 2012. The Transition Support Program emphasizes patients’ medical, health and safety issues following discharge.
“A major objective of the program is to prevent rehospitalization, which is emphasized in the federal Affordable Care Act, and to keep our patients healthy and safe at home,” Martin said. The new program is being funded through Shepherd Center operational dollars.
Martin and her staff are seeking grants to expand program services in the future. Also, the program will benefit from recent funding Shepherd Center received from the Patient-Centered Outcomes Research Institute (PCORI) for the project “A Patient-Centered Approach to Successful Community Transition After Catastrophic Injury.” This project is evaluating the impact of several systems changes aimed at minimizing hospital readmissions and focuses on revising Shepherd Center’s discharge planning and post-discharge supports for patients and families.
Giving it an edge already, the Transition Support Program is staffed with employees experienced in meeting the needs of Shepherd’s patients as they return to their homes and communities, Martin said.
Transition support coordinators accomplish the program’s mission through a combination of phone calls, tele-health sessions and home visits with patients. They work with patients and their families to develop person-centered plans to manage disability and medical issues. Topics they address include medication management, safety and fall prevention, physician follow-up appointments, health record management, and schedule and routine management.
This part of the program serves people referred by their Shepherd Center treatment team and deemed at high risk for rehospitalization and/or those who face socioeconomic challenges and/or limited family support.
Meanwhile, the Transition Support Program’s peer support staff members are reaching out to Shepherd Center inpatients. They are increasing peer mentoring and education for inpatients on both a one-on-one and classroom basis. Classes focus on topics including self-advocacy and disability management. Peer supporters will soon launch a Facebook page to give former patients with spinal cord injury a forum to offer insight to one another.
Also, the program’s vocational services staff is helping patients who are referred by their treatment team because of their plans to return to work or post-secondary education.
The Transition Support Program, which is overseen by Sarah Morrison, vice president of clinical services, is working with departments throughout the hospital to accomplish its mission. Already, staff members have collaborated with spinal cord and brain injury educators and public relations staffers to develop training and educational videos for use with inpatients, as well as patients who have discharged from the hospital. This information is housed on a new educational website at MyShepherdConnection.org, which launched in spring 2013.
Shepherd Center provides world-class clinical care, research, and family support for people experiencing the most complex conditions, including spinal cord and brain injuries, multi-trauma, traumatic amputations, stroke, multiple sclerosis, and pain. An elite center recognized as both Spinal Cord Injury and Traumatic Brain Injury Model Systems, Shepherd Center is ranked by U.S. News as one of the nation’s top hospitals for rehabilitation. Shepherd Center treats thousands of patients annually with unmatched expertise and unwavering compassion to help them begin again.