Teresa Radford helped to pilot the PH Medicine HOME program beginning in 2018 leading the pilot to become a fully dedicated program to address the very high needs of patients who require comprehensive interdisciplinary, patient-centered care with seamless continuity upon discharge. Her work is to meet patients where they are, identify and educate them on individual care goals, improve health equity, work with any system to address needs, and deliver inter-professional, non-traditional, and inclusive care through teams and the patient/their family/caregivers/community-based assistance support. Most patients she provides care to are among the top 1% of utilizers in inpatient care at UVA Health Medical Center. 

In 2019, the program received the Charles L. Brown Award for Excellence in Patient Care and many presentations have been made across the nation centered on providing individualized care to the highest utilizers of hospital-based care. 

However, the most impactful outcomes take place through the absolute dedication, tenacity, and commitment of one, Teresa Radford. Almost every week, I receive multiple communications recognizing the awe-inspiring efforts of Teresa on behalf of the patients served through the HOME program. In the past 90 days, she has placed two of the most complex patients we've treated in the ED, inpatient, and outpatient facilities. Through these placements, the lives of these patients now exceed the team's hopeful ICP outcome. She'll tell everyone it takes a village, but there is no doubt, the success of these patient placements and care is happening through her tenacity, commitment, and skill. 

In order for you to understand the patient complexity Teresa manages, below is just one patient history.

Homeless, geriatric patient, end-stage renal disease needing dialysis 3x/week, CVA, left-sided with residual right-sided hemiplegia, diabetes (since 12yo), bipolar disorder--cluster B traits, schizoaffective disorder, mild intellectual disability, wheelchair-bound 

The mission of UVA Health is, "Transforming health and inspiring hope for all Virginians and beyond." If you knew how many patients Teresa has held the hand of in the dark of the night, met on the streets to provide care to, sat on a bench with to discuss needs and listened through desperate tears, you would know that not only is she transforming health and inspiring hope, but she is doing this for patients others have or would give up on due to the complexities and challenges each one faces. 

She never gives up and she's been there through many successes and also through painful losses. She's building bridges within UVA Medical Center's many systems and throughout communities in the state of Virginia. She provides hope to patients and team members and care in ways no one else does at UVA Health. With every patient, she addresses inequities and disparities and always works with the utmost professionalism, integrity, and respect for all. 

I've told her so very often, there is rarely a day where I'm not in awe of what she does and how she manages to connect the resources to address the needs to resolution. RESOLUTION in this patient population! It's beyond challenging to manage these patients while they are inpatient let alone, prevent readmissions, overdoses, non-emergent ED visits, high utilizer 911 calls, and the bleakness of a cold night for anyone who is homeless. 

She has provided assistance and guidance to obtain meals, establish care with a primary care physician, clothing, shelter, utilities, medication, transportation, and so much more. She is driven to ensure the safety and well-being of a patient population often forgotten or displaced due to the complexity of medical and social determinants of health needs. 

Not only does she live this Monday through Friday, but also on Saturdays, Sundays, evenings, weekends, and holidays. She knows these needs don't stop because a clinic is closed. 

Several community leaders have sent me emails or called to make sure Teresa is recognized for her valiant and often unspoken care for so many. I have recognized her through emails to our CNO, our Chief, and ASPIRE bonuses and of course, she expects nothing because this is truly her calling. 

If anyone embodies and is a role model for compassion, always goes above and beyond, creates care and fosters compassion beyond hospital walls, is trusted, respected, and encourages every single one of us and so many in the community to address the needs of our highest complexity patients in the post-discharge world while also working to achieve better outcomes--it is Teresa Radford.

Note: This is Teresa's 2nd DAISY Award!