An innovative community health model for care transition has been launched in Wheeling, West Virginia.
Catholic Charities West Virginia (CCWVa) has piloted a Hospital Transition Program in partnership with WVU Medicine Wheeling Hospital. The program provides a supportive transition for high-risk patients as they are discharged from the hospital.
“For people who have been in the hospital for a few days or more, returning home can be daunting — especially if they don’t have a lot of family or social support,” said Mark Phillips, CCWVa Northern Regional Director. “Our Hospital Transition Program, in partnership with WVU Medicine Wheeling Hospital, helps to provide people with a sense of confidence and comfort as they transition from hospital to home.”
The Hospital Transition Program aims to serve people with higher risk factors for negative health outcomes. Persons admitted to WVU Medicine Wheeling Hospital are screened for certain social determinants of health – external environmental circumstances or factors that could contribute to decreased health and wellness. Examples include unstable housing, lack of steady income, lack of transportation or community technology, etc.
“We feel strongly that we at CCWVa are experts in providing compassionate care to those affected by these complex social determinants of health,” said Sara Lindsay, CCWVa Chief Program Officer. “Supporting people with their social and environmental needs, on top of their basic medical needs, involves a level of experience and skill to meet people where they are and accept their situations, unconditionally, as a starting point on their health journey.”
Initial funding for the program was provided by Catholic Charities USA.
Returning Home with Confidence
After sustaining injury from a severe fall at her home, Wheeling resident Laurie Quinn was admitted to WVU Medicine Wheeling Hospital. Upon discharge, Quinn was connected with Sister Jen Berridge, CCWVa Hospital Transition Program Case Manager.
Berridge worked with Quinn to develop a plan to holistically support her in her transition home, ensuring Quinn understood discharge instructions and was connected to community resources.
“Sister Jen has been a very big help,” said Quinn. “She has helped me out with food orders, with blankets and pillows, and a chair for me to get in and out of more easily, because when I got hurt it was hard to sit down.”
The Hospital Transition Program focuses on basic chronic disease management, home safety, support networks and food security from a nutritional angle.
“Through this Hospital Transition Program, we are able to do great things for the people who need it the most,” said Deacon Paul Lim, WVU Medicine Wheeling Hospital Vice President of Mission Integration. “WVU Medicine Wheeling Hospital is so proud to have this truly unprecedented partnership where patients now have access to the array of services at Catholic Charities West Virginia. This is going to change the lives of so many and pave the way for even stronger collaboration moving forward.”
By Katie Hinerman Klug, Marketing Communications Specialist
