Wheeling hospital partners to support recovery of high-risk patients after hospital discharge

October 1, 2022


The Hospital Transition Program, a collaboration between WVU Medicine Wheeling Hospital and Catholic Charities West Virginia, both in Wheeling, provides individualized support to vulnerable, low-income patients after their hospital discharge.

Deacon Lim

"Even if we didn't have a formal program, this would have happened organically," said Deacon Paul C. Lim, vice president of mission integration at the 250-bed hospital. "We are a Level 4 Trauma Center — the first line of defense for the Upper Ohio Valley — and we are collaborating with the largest provider of charitable and social work in West Virginia. Along with the diocese (which sponsors WVU Medicine Wheeling Hospital), we're all right here in Wheeling, serving the same people."

Sara Lindsay, chief program officer of Catholic Charities West Virginia, said the Hospital Transition Program was conceived as a backstop for patients with specific vulnerabilities and a higher likelihood of hospital readmission. "We want to be a safety net to catch those individuals where the hospital systems simply do not have the capacity to do so. In that way, our goal is to be of service to our fellow service providers as well as the clients themselves.

"It is a wonderful opportunity for us to show what we can accomplish together. Our intent is never to compete with or replace existing hospital services" including support provided by hospital social workers, care managers and others, Lindsay said. Before the program launched, Catholic Charities West Virginia through its Wheeling Neighborhood Center was already providing services for patients who had been discharged recently from Wheeling Hospital.

Sr. Jennifer Berridge, CSJ, left, a case manager at Catholic Charities West Virginia, visits with Laurie Quinn, a client in the Hospital Transition Program. The program, a collaboration between Catholic Charities and WVU Medicine Wheeling Hospital in Wheeling, West Virginia, meets practical needs of vulnerable patients following hospital discharge.

"We share in the collective care of these folks whether we coordinate and work together or not. So, it makes sense all around for a project like this to streamline service provision for the care providers, while alleviating undue suffering of those patients," explained Lindsay.

Better together
The Hospital Transition Program is funded by a two-year grant for $333,333 from Catholic Charities USA. Catholic Charities West Virginia competed against other Catholic Charities agencies of similar size in the U.S. and won a one-third share of a $1 million grant.

Launched in December 2020, the Hospital Transition Program focuses on basic chronic disease management, home safety, support networks and food security and nutrition.

Lindsay said Catholic Charities West Virginia is committed to the Hospital Transition Program and has expanded it to St. Mary's Medical Center and Cabell Huntington Hospital, both in Huntington, West Virginia. Catholic Charities West Virginia received private donations for the expansion to Huntington and continues to apply for grant funding to underwrite the overall program.

Not to worry
Sr. Jennifer Berridge, CSJ, a case manager at Catholic Charities West Virginia who is the agency's boots-on-the-ground in the transition program, said, "Our mission is to serve the most vulnerable, and the collaboration with the hospital is really important. So far, we have helped about 100 individuals."

Sr. Berridge recalled working with a woman in her late 40s whose chronic health problem had resulted in a 90-day hospitalization. "Last fall, when I went to her room, she told me she was worried about how to pay her (household) bills and manage things after being discharged," Sr. Berridge said. "I told her not to worry. I secured emergency assistance funds, got the bills and paid them, and I also arranged for some basic groceries. She's home now, and doing well."

Another patient, a homeless individual, had refused to move to a shelter when he was discharged after heart surgery. Sr. Berridge got a call saying the man, who required supplemental oxygen, was living in his car. She secured an apartment for people with disabilities, paid the security deposit and two months' rent and nailed down sources for furniture and food before approaching the man, who accepted her offer of a safe place where he could recuperate. "These are the kind of patients who keep me up at night," she said.

Someone to talk to
Her schedule on any given day may include such tasks as arranging delivery of a hot meal to a discharged patient or writing a letter affirming that an individual is homeless and stating that he or she needs services. A network of housing agencies can then provide rentals for people who qualify by income or disability status.

Sr. Berridge said, "I know I'm doing what I can for those most in need, and any of my success stories are really about those moments where I could help someone."

Some people just need to talk, and Sr. Berridge makes time for that. Ensuring a person has adequate social supports is an important piece of the Hospital Transition Program. For longer-term support, Catholic Charities West Virginia can connect individuals to its regular services.

Deacon Lim, who is spreading the word about the support available through the program for patients in economic need, counts himself as Sr. Berridge's biggest fan.

"The hospital can take care of health issues and everyone admitted is screened for social determinants, but so often we concentrate on medical necessity, whether a person needs a prescription, an X-ray, a treatment or a visiting nurse after discharge. Sr. Jen goes into patients' homes, or at least to their front porches, and sees what else people need — and Catholic Charities has an array of services to help people."

For example, after Sr. Berridge reported a patient was having trouble getting out of a chair, the Hospital Transition Program was able to provide a power-lift chair.

Impoverished state
The Wheeling program is loosely modeled after a hospital transition support program the Archdiocese of Chicago started with Medicare funds made available through the Affordable Care Act.

Access to health care in West Virginia, Deacon Lim noted, is quite different than in Chicago. The population of West Virginia is very spread out, and it's often hard for people to get to where they need to go for assistance.

In 2021, West Virginia was among the top 10 poorest states, with a $48,850 median household income and a poverty rate estimated at 15.8% by the Economic Research Service of the U.S. Department of Agriculture.

Poverty, of course, influences life expectancy, and as of 2020 West Virginia had the second shortest life expectancy of any state in the U.S. — 72.8 years, according to the National Vital Statistics Reports. The average household income in Wheeling is about $67,400, with a poverty rate of 13.84%. According to the Census Bureau, the national poverty rate in 2020 was lower, at 11.4%.

The University of Notre Dame's Wilson Sheehan Lab for Economic Opportunities assesses poverty interventions to identify and share effective programs. The lab will work with Catholic Charities West Virginia to evaluate the impact of the Hospital Transition Program.

Lindsay said the hope is the lab will be able to demonstrate community-level cost savings from the Hospital Transition Program through reductions in avoidable hospital readmissions. "As long as the data supports it, our sustainability plan also includes potential hospital network contributions for ongoing services, she said. Wheeling Hospital has already contributed to the project financially, as a pilot. This is how the Chicago project has sustained their program, as well."

Deacon Lim has seen its benefits firsthand.

"Some people who come to our hospital are not seeking health care, but need access to resources for their basic needs," Deacon Lim said. "Some have no jobs, no health insurance and no money. Since coming to Wheeling in June 2021, I've been really moved by the economic instability and the poverty here.

"We have a small food pantry that hospital employees contribute to, and Sr. Jen determines when someone needs groceries," he said. "When she comes into a room smiling and bearing necessities — well, that's a positive outcome."


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