Delivering 360 Degree Patient Care: Lost and Found, Home Repair to the Rescue

 Updated: May 16, 2018

  Tags: Patient FocusPatients

Image of Michele Sawyer and team members
Michele Sawyer, center, gathers with team members at Bon Secours St. Francis Health System, from left to right, back row, Joseph Whitten, RRT, director of respiratory and Alex Garvey, PhD, senior vice president of mission; front row, Julie Jackson, RN, left, and Kathleen Burgess, MCM, MeD, RRT, right.

Patients are, first and foremost, people. And like any of us, they are dealing with lots of different things at any given time. Some of those things can affect the management of their respiratory conditions.

In this second installment of our 360 Degree Patient Care series, two therapists explain how they go the extra mile.

Lost and found

Image of Buffy Chapman
Buffy Chapman, BA, RR

As the COPD navigator for Lexington Medical Center in West Columbia, SC, Buffy Chapman, BA, RRT, provides her patients with COPD education and coordinates with the interdisciplinary team to ensure patients receive help with medications, follow up appointments, transportation, financial assistance, and anything else they need.

Patients go home with an action plan magnet that helps them review daily status, along with a self-management toolkit complete with a graduated cup, pedometer, pulse oximeter, respiratory medication organizer, and pillbox.

When patients need her to go to bat for them outside of the clinic, she’s ready to step up to the plate.

“I had one particular patient whose noninvasive ventilator had been lost by a skilled nursing facility after a previous admission,” Chapman said. ”The patient had several subsequent admissions and it was determined the only thing that would keep her from readmitting and restore her quality of life was the use of the missing equipment.”

Unfortunately, none of the parties involved was willing to take responsibility for getting her that equipment.

Chapman jumped in and found a provider who was willing to lend her a machine at no cost, and she also worked with the patient’s daughter on dietary concerns arising from the patient’s comorbid congestive heart failure, helped them apply for financial assistance, and filled in a number of other gaps as well.

“She has only had one admission since that time and this was over one year ago,” Chapman said.

Home repair to the rescue

A transitions of care team at Bon Secours St. Francis Health System in Greenville, SC, is led by the director of respiratory care and includes a clinical education coordinator, an RN, two paramedics, and Michele Sawyer, RRT.

“We focus on Medicare COPD bundle patients and VBP pneumonia patients,” Sawyer said. ”We see them in the hospital and transition with them to home or skilled nursing.”

She provides her patients with the education they need to self-manage and assesses their social, physical, and emotional issues, along with their level of family support.

Occasionally that means getting involved in more than just the patient’s respiratory care needs, as was the case with one patient who was ordered oxygen upon discharge.

It wasn’t until she had to be readmitted that the team learned her living conditions were so unsafe that the oxygen could not be set up.

“She stayed in the hospital and transitioned to skilled nursing until our team — with the huge support of our mission’s team at the hospital with a local church partnership — was able to completely clean out her house and repair her plumbing, rotted out floor, and electric to make a safe discharge to home,” Sawyer said.