An Interview with Melissa Roberson, RN, BSN, CCM, Care Navigator
Henry County Medical Center (HCMC) is a 142-bed acute care facility located in Paris, Tennessee. Between 2015 and 2020, Henry County Medical Center reduced all-payor, all-cause, 30-day hospital readmissions by 31% and is sustaining that success into 2022. One of its successful strategies was the addition of a dedicated care navigator who maintains early and regular post-discharge patient/family contact to ensure a smooth post-discharge course.
We interviewed Melissa Roberson, RN, BSN, CCM, Care Navigator, to learn more about Henry County’s readmissions reduction strategies. Melissa has worked at HCMC for 11 years and been involved with readmissions in some form the entirety of her tenure. She says, “I have found there is no easy answer. You must treat each patient as the individual they are. What works for one, may not work for the other. I think the key is just being proactive and staying on top of things, always striving to improve. I have been in healthcare since 1989, and it is always changing, so you have to be willing to change with it.” Melissa offered that all HCMC case managers assist in screening patients for post-discharge needs. Case managers aim to identify needs early on and ensure they leave with everything set up. If there is a patient who a case manager is concerned about succeeding at home, they alert Melissa, so she can follow up on their concerns once the patient is discharged.
Read more about Henry County’s readmissions reduction strategies below.
Tell us about your experience of following a patient from discharge through nursing home admission to identify gaps in care transition.
HCMC has two local skilled nursing facilities (SNFs) to which most patients are discharged. I followed one patient at each facility through the discharge process from HCMC to the admission process at the SNF. I tried to gain a perspective according to what the patient was going through. This was very helpful, and I highly recommend it to other facilities.
How has HCMC built relationships with nursing homes in the area?
HCMC had Community Transitions Meetings prior to COVID, and we hope to get these back on track if COVID numbers remain low. We met quarterly with local nursing homes, home health agencies, and rehab facilities to identify any issues with the discharge process and transition of patients throughout the healthcare system. This allowed everyone to get to know each other and seemed to promote continuity of care.
Tell us a little about your joint class.
Henry County revamped the ortho class in 2015 for patients having elective orthopedic surgery. The ortho class started as a strategy to ensure patients are as prepared as possible for surgery. I attend this class to give patients my contact information, so they know how to reach me for any questions they may have prior to or after surgery. Patients fill out a questionnaire that lets me know if they have all the equipment they need, physical therapy set up, and help at home. A pharmacist attends this class to go over their medications as well as a physical therapist who goes over exercises to do pre/post operatively.
Tell us about the follow-up phone call system HCMC used.
For almost five years we used an automated system that made calls the patients could respond to by pressing certain keys on their phones. I met with patients to teach them about the system while they were in the hospital, and even did a test call with them, so they were more likely to respond once they were home. There was also a key that patients could push to request that I call them. Unfortunately, the system was discontinued in May of 2020, so I am now making the follow-up calls directly. However, the system was very instrumental in getting the program going and identifying issues. It allowed us to get the major problems fixed before the system stopped. It called patients three times a week and if anything flagged, the system would send me an email, and I would follow up. We were able to call a lot of patients this way;, otherwise, I would not have been able to contact patients as much on my own. The system also allowed for a change in frequency of calls to a patient and could be set up to give medication reminders if needed.
How does Henry County Medical Center approach discharge teaching?
As stated above, the orthopedic patients start discharge teaching during ortho class. For other patients, there is a pharmacist on the floor that instructs them on their medications and any changes that have happened during their hospital stay. The nurses on the floor do discharge teaching with all patients prior to discharge. Then I call all inpatient admissions the day after discharge to ensure they understand everything.
Do you make follow up appointments for patients?
The unit secretary typically makes follow up appointments for patients. However, when I call the patients, I ensure they have their follow up appointments. Orthopedic patients have their follow up appointments scheduled before they come in for surgery.
How do you help patients with their discharge medications?
There is a pharmacist that goes over patients’ medications prior to discharge. I call patients the day after discharge to ask them if they have all medications filled and understand how to take them.
How do you manage issues that you discover on follow-up phone calls?
If it is an issue where a patient needs to see their primary care provider, I call and make them an appointment. If their provider is one of the nurse practitioners or physicians hired by the hospital, I can get into the system and schedule their appointment. If it is questions about medications or their disease process, I answer them. If I cannot, I arrange for someone to call them that can. It just depends on what is going on with the patient.
Tell us about the system that alerts when a recently discharged patient returns to the ER.
HCMC has a tracking board in the ED. It is programmed to flag the patient if they return for any reason within 30 days. This alerts the physicians and the nurses. There is a case manager that is in the ER off and on throughout the day. She tries to watch for possible readmissions that may come through. HCMC tries to evaluate and get patients back home with what they need to prevent them from being readmitted, but if they need to be admitted to the hospital, they are. Sometimes they just need home health set up, home O2, or even hospice. Other times they realize they should have gone to a SNF. I have the ER tracking board on my computer to look at frequently throughout the day to spot any potential readmission.
Is there anything further you would like to add?
I would like to add that HCMC is very fortunate to have received funding through the Delta Rural Health Initiative to help cover the cost for my position. HCMC also has a Chronic Disease Case Management program patients can go through post-discharge that the grant helps fund. The program provides several classes on chronic diseases as well as pharmacy assistance.