GILLETTE, Wyo. (AP) — When John "Chuck" Lenferink was being readied to fly from Campbell County Memorial Hospital to Denver in August, he turned to Angela Roesler and said, "This is going to kill me, isn't it?"
The nurse looked at her 68-year-old chronically ill patient and told him "yes." If he didn't make some big changes, and soon, his chronic obstructive pulmonary disease (COPD) and congestive heart failure would be the death of him.
At the time, Lenferink was averaging one hospital stay and at least two emergency room visits per month. If he wasn't in the hospital for heart failure, it was for COPD. He was overweight, he couldn't breathe without oxygen and things were only getting worse.
Lenferink is stubborn. He'll be the first to say he doesn't like being told what to do. But faced with his own mortality, he knew he needed to listen to his favorite nurse.
"When he came home, he was a changed man," Roesler said.
Roesler loves being a nurse, and she also loves to teach. When the hospital decided to create a transition care program in May, she was ecstatic.
"It's the best of both worlds," she said.
Roesler had been an acute care nurse in the medical surgical department since 2009, but the change to a transition care nurse was easy.
"It's about the people," she said. "I love my patients, and I love this job."
The hospital was able to implement the program with the help of a grant from the Wyoming Rural Care Transition Program based out of the Cheyenne Regional Medical Center. The program is one of several recently formed by the Wyoming Institute of Population Health, which received a $14.2 million grant from the Centers for Medicare and Medicaid Services.
The grant is paying for one full-time and one part-time care transition nurse at the hospital.
Under the grant, participating patients must be 65 or older and have one of the 10 most common diagnoses for readmitted patients, which are: congestive heart failure, COPD, coronary artery disease, diabetes mellitus, stroke, hip fracture, peripheral vascular disease, pulmonary embolism, chronic back pain and cardiac arrhythmia.
The nurses meet with at-risk patients while they're still in the hospital and then do a home visit once they are discharged.
"We don't do any acute assessments. We don't take blood pressures. We don't do what public health and home health agencies do," Roesler said. "We don't compete with them. We're kind of an adjunct to them."
The nurses act as a liaison between the patient, their doctors and the hospital. Their main goal is education and empowerment.
During the first home visit, the transition care nurses go over the discharge information that the hospital gave the patient and come up with an action plan.
The biggest challenge during the first visit is medication reconciliation, Roesler said. The nurse and patient go through all the patient's medications together and outline which pills the patient should be taking, how often and why.
Once a plan is established, transition care nurses continue to make contact with their patients either by phone or in person at least once a week to check in. Often times, the biggest hump for patients to overcome is to be able to identify negative symptoms and call the doctor.
"We prefer that they just make the doctor's visit, but most of the time that isn't their first thought. They wait, and then they end up in the ER and then typically end up admitted," Roesler said. "We're trying to catch that just by asking really pointed questions in those weekly phone calls."
The nurses can follow a patient for up to 90 days, but Roesler said most of the patients that she's seen go through the program are ready to be back on their own in 30 to 60 days.
"We know they're ready to discharge because they've taken control. They've gotten to the point where they can self-manage. They're able to identify symptoms, and they know what to do about them," Roesler said.
Sometimes, taking control can mean a patient is ready to transition into hospice care. As long as the patient is able to identify what's best for them, to Roesler, it's a success.
"This is a great program. I'm very thankful the hospital decided to do it," Roesler said. "It's definitely made a difference in the lives of real people."
Since the program started at the hospital in mid-May, 140 patients have opted for the extra care. It's paying off for both patients and hospital, Roesler said.
"It's not a time-driven program, so you get time with your patients, and you get to invest in them and in their success," she said.
Patients are taking control of their health, and the hospital is seeing its readmission rates go down for patients 65 and older.
"I think it's a good fit for every community, honestly," Roesler said. "It probably works well here because we are a community-focused hospital. We're it. So when people go to the hospital, they're going to come here, and when they go home they're going to look back to us to help them succeed at home."
Lenferink signed up for the transition care program for that exact reason — he needed to be able to stay healthy at home.
Lenferink started working with Roesler in May. After being faced with death in August, he took complete control of his health, and it shows.
When he was flown to Denver in August, Lenferink weighed 316 pounds. He now weighs a healthy 211. While he still breathes with oxygen assistance, he is able to go without it if need be.
He credits all of his success to his nurse, Roesler, and his wife, Erika.
"Once you've lost your health, you have lost everything. Period," Lenferink said.
Now that he's in better health, he appreciates it.
"I've gotten better, and I mean better," he said. "I'll never go back to my baseline, whatever that was, but I have a new baseline, and I'm feeling better."
Not only did it benefit Lenferink, but the program helped his wife, too.
Erika, 63, is his caretaker. Before Roesler, she said she felt alone at times. She's grateful the program was developed, and the timing couldn't have been better for the couple.
"I have the security because I know I can call her. She said I could, and she even gave me her cellphone number so I can call in the middle of the night," Erika said about Roesler.
The hospital doesn't charge patients to use the service, and it's not getting reimbursed for it. The hope is that the program will work so well that the hospital will continue to provide the service once the grant stops paying the nurses' salaries.
"It's the right thing to do for the patients, and that's what I love," Roesler said. "If it's the right thing to do, then let's keep doing it."
Information from: The Gillette (Wyo.) News Record, http://www.gillettenewsrecord.com