Team Helps Heart Failure Patients Stay
Out of the Hospital

Amy Bragg, R.N., left, and Allison Short, R.N., keep track of high-risk patients, making sure they get the services they need to remain healthy enough to stay out of the hospital.

It was 1996 and Amy Bragg’s toddler Timothy was gravely ill, battling a parasite that caused four bleeding ulcers. It took two years and numerous trips to the doctor’s office, hospital and emergency room before Amy, a licensed vocational nurse at the time, was able to make sense of it all and get him the treatment he needed to heal.

She was at times furious with the system, and remembers seeing a copy of his medical records later where she was described as “hysterical.” But in the true spirit of being an advocate, she kept her focus on the patient who today is a healthy young man.

It was her first brush with complex case management, but by no means her last.

Amy, now a registered nurse, has partnered with Allison Short, R.N., to help NorthBay Healthcare’s heart failure patients with complex problems navigate an equally complex system to get the care they need, when they need it.

The program was developed out of a pilot project launched in 2014 by Shelley Stelzner, director of Case Management.

“The goal was to provide assistance maneuvering within the healthcare system, for diagnosed heart failure patients,” explained Shelley. “We know they are among the patients most likely to return to the hospital for a variety of reasons.”

Shelley’s pilot identified 22 high-risk patients and connected them with Amy.

The trial proved successful: Recidivism dropped 13 percent over a four-month period. The pilot ended in August and the program went live in November of 2014. “We could see we were making a big difference,” says Shelley.

Some of the tools developed during the program are still being used, including a heart failure workbook created by a NorthBay team including Case Management, Pharmacy, Nutrition, Social Services, Home Health and Cardiac Rehabilitation. It covers the basics and offers insights to people who may have never worried about diet and exercise before.

“We developed a vision with this program that we needed to be proactive, not reactive,” explains Amy.

Sometimes that means connecting a patient with a cardiologist, other times it means teaching them about the importance of exercise and good nutrition.

In a recent case, one of Amy’s patients needed help getting healthy food, so she introduced him to Meals on Wheels. She even found a financial counselor who managed to establish insurance for him.

“We keep track of these folks, and so far he’s managed to stay out of the hospital for 90 days,” says Amy. “That’s a success.”

Patient issues are many, and varied. “Sometimes they are addicted to drugs, alcohol or cigarettes, and it’s a real challenge to keep them on track,” she says. “It’s not just following heart healthy guidelines, but staying sober or giving up a longtime habit.”

And sometimes, it’s living conditions. Amy has helped patients who are homeless and some who are leaning on family members for support.

“It’s not always the best situation,” she says. “We try to take their needs into account and do what we can. Sometimes, we have to be flexible.”