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After Covid-19, Patients Come Home

A New Jersey health center has a program designed to get patients released from the hospital the medication and follow-ups they need.



Transitions of Care pharmacist Rachel Rivera in consultation. (Photo courtesy of Henry J. Austin Health Center)

In September of 2019, pharmacist Rachel Rivera created a new program designed to get patients who had been hospitalized the resources they needed.

“Patients who were coming out of the hospital…were feeling lost about what to do next,” Rivera explained.

She was particularly concerned about the patients at her community health center – Henry J. Austin Heath Center in Trenton, New Jersey – who found navigating the complex medical system a challenge. Many didn’t understand the follow-up care instructions they’d been given, or couldn’t afford the medications they’d been prescribed. And many of them changed their phone numbers frequently, making them harder to get hold of – and more likely to fall through the cracks.

“Patients are admitted, they are not necessarily treated appropriately…and then within 30 days they are back in the hospital,” Rivera said. Her Transitions of Care program aimed to prevent that by ensuring that patients filled their prescriptions and understood their at-home instructions – as well as getting a fast follow-up appointment with a provider to ensure that they were continuing to recover.

A $200,000 grant provided by Direct Relief, as a part of the BD Helping Build Healthy Communities program, was used to expand Henry J. Austin’s Transitions of Care program.

At first, most of the patients she worked with had been hospitalized because of issues related to chronic disease – chronic obstructive pulmonary disease, for example, or diabetes.

But beginning in 2020, she was confronted with a new challenge – patients who’d been hospitalized with Covid-19, and were returning home to recover.

Dealing with the aftermath of the disease was both new and worryingly familiar – sorting out medications, setting up meetings with providers, getting unmanaged conditions under control.

Pharmacist Rachel Rivera, right, began the Transitions of Care program in 2019. Beginning in 2020, she began helping Covid-19 patients who were released from the hospital. (Photo courtesy of Henry J. Austin Health Center)
Pharmacist Rachel Rivera, right, began the Transitions of Care program in 2019. Beginning in 2020, she began helping Covid-19 patients who were released from the hospital. (Photo courtesy of Henry J. Austin Health Center)

For one thing, Rivera said, the medications her patients were being prescribed were often beyond their means – up to $800 in some cases. With an in-house charitable pharmacy, Henry J. Austin was able to get the medication to patients for a maximum of about $10.

For another, she was concerned about the condition of some of her patients. Rivera described a diabetic patient who had been hospitalized for Covid-19, and who emerged from the hospital with high A1C levels – an indicator of unmanaged diabetes.

“He’s in the hospital for a month. His blood sugar should be amazing,” Rivera said.

To make things worse, he had complex at-home care instructions that required two different insulins, and didn’t understand what he needed to do. Rivera spent time with him on a virtual platform, slowly going through all the instructions until he felt confident in his ability to take his medications and follow other instructions.

Another patient, recovering on oxygen, had an ongoing cough that was keeping her awake at night. “That wears on a patient,” Rivera explained. “That’s going to decrease their ability to care for themselves during the day.”

But Rivera is proud of the steps she’s taken to help Covid-19 and other patients recover. One of the secrets of her success is a resource that’s rare everywhere, but perhaps especially in health care: time.

“As a clinical pharmacist I have half an hour to devote to one patient, which a primary care provider does not have,” Rivera said. “Just spending that quality time” can make a tremendous difference.

Rivera keeps a close eye on the local health information exchange to see if Henry J. Austin patients appear in local hospitals. If one appears, she reaches out to them and offers to coordinate their post-hospitalization care, filling their prescriptions, walking them through instructions, and getting them in to see a provider within two weeks. She prides herself on being easy to reach, especially by health care standards.

But she stresses that the medical system is difficult to navigate, especially for patients with little health literacy. Programs like hers have an important intervention to make.

And yet, Rivera said, programs like her are relatively uncommon among primary health care providers. She estimated that they number in the hundreds rather than the thousands.

Tom Bateman, Henry J. Austin’s lead clinical pharmacist, explained that many similar programs are run by hospitals, rather than health centers. And locally, “there isn’t really a program for that smooth transition” that’s based in a primary care setting, he said.

Over the holiday season, Rivera saw a number of Henry J. Austin’s patients had died of causes related to Covid-19. “The first week [of 2021] was hard,” she said.

But since then, her patients have had good luck. “We have patients with mild cases, or they’re in the hospital for a month, they’re getting remdesivir and they’re getting convalescent plasma,” she said. “But they’re making it.”

For more information about Henry J. Austin Health Center, a federally qualified community health center that treats patients, regardless of ability to pay, visit their page here. More information on BD’s Helping Build Healthy Communities program can be found here

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