Northridge Hospital Foundation Received a Gift of $372,651 from UniHealth Foundation for Our Chronic Disease Transitional Care Program

When faced with a medical issue, an additional layer of comfort and support makes all the difference. Consider Louise, an 87-year-old frail elderly patient, who was admitted to Dignity Health - Northridge Hospital after falling and fracturing her upper leg. Not only did she receive expert treatment while undergoing surgery to repair the fracture, she was also a candidate for our Chronic Disease Transitional Care Program. The program is improving the patient experience before and after discharge and decreasing avoidable 30 day chronic disease readmission rates. It serves moderate to high risk adult chronic disease patients with congestive heart failure, stroke, cancer, chronic obstructive pulmonary disease, end-stage renal failure, and the frail elderly.

Alison, one of the Nurse Practitioner Care Coordinators for our Transitional Care Program, saw Louise at the hospital and post-discharge at Topanga Terrace, a Skilled Nursing Facility (SNF). Patients in the program are seen at home/SNF within three days of discharge to revalidate continuity of services, provide community resources, equipment, understanding of red flags of illness, medication reconciliation, and to ensure follow-up appointments are met. Patients are also called at least once a week or more (if needed) for updates on their condition.

In Louise’s case, her family contacted Alison when her leg became swollen because they were concerned she had a blood clot. Alison spoke with them about the ultrasound, which showed that there was no blood clot and reassured them that the swelling would go down. At a later date, Louise spit up a small amount of blood and again the family became alarmed. Alison returned to the SNF and checked the patient’s vital signs, oxygen level and breathing, which were fine but informed the family of “red flags” that could develop.

According to the family, Alison’s involvement kept Louise from returning to the Emergency Department on several occasions. Louise’s niece commented that, “Knowing we could call Alison anytime and get our questions answered quickly helped relieve our worries. Alison was our security blanket. She also provided a great deal of emotional support and was compassionate, which helped my aunt who was very depressed.”

Today, Louise is returning to her independent and active lifestyle. She and her family are thankful for the support provided by Alison and the Transitional Care Program.