Northridge Hospital Foundation Receives $1.1 Million Grant for Chronic Disease Program

Northridge foundation receive funding for chronic disease program.Northridge Hospital Foundation received a three-year grant for $1.1 million from UniHealth Foundation to support a chronic disease transitional care program. The program 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.

Patients are seen within three days of discharge to revalidate continuity of services and provide community resources, equipment, understanding of red flags of illness, medication reconciliation, and ensure follow up appointments are met. Patients are called at least once a week, or more if needed, for updates on their condition. The program is improving the patient experience before and after discharge and decreasing avoidable 30-day chronic disease readmission rates. 

How this program makes an impact

Louise, an 87 year old frail elderly patient, was admitted to Dignity Health Northridge Hospital after falling and fracturing her upper leg. She underwent surgery to repair the fracture. Alison, one of the NP Care Coordinators for the Transitional Care Program, saw Louise at the hospital and post-discharge at Topanga Terrace, a skilled nursing facility.  

The 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 nursing facility 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.”  Louise is returning to her independent and active lifestyle. She and her family are thankful for the support provided by Alison.