The Congregational Health Ministries (CHM) was developed by Rebecca Heitkam in an effort to carry on the Mercy mission. The mission is: Furthering the healing ministry of the Sisters of Mercy, Emory Saint Joseph's Hospital gives tangible expression to Christ's merciful love by providing compassionate, clinically excellent health care in the spirit of loving service to those in need, with special attention to the poor and vulnerable. The CHM has programs that provide care and resources to patients within the hospital as well as to people in their communities. The CHM programs are the Faith Community Nurse Navigator Program, the Diabetes Prevention Program, and Discharge Planning.
Terri Burnham is the Lead Coordinator of the Faith Community Nurse Navigator Program. She leads an innovative team of paid and volunteer Faith Community Nurse Navigators (FCNN) who become navigators for patients with complex, chronic conditions. The FCNNs commit to partnering with patients to help them develop and hone self-management skills that improved their quality of life and/or their health outcomes. The FCNNs provide holistic care of the body and spirit. Sandra Price was a volunteer FCNN who was so passionate about the program mission that she took a full-time FCNN position to better support patients through their healthcare journeys.
From the very start of the program in April 2017, patients expressed that their FCNN was the perfect person to help them manage their care in the home setting. The FCNNs and patients quickly developed therapeutic relationships/partnerships. The FCNNs were able to help their patient partners identify symptoms of deterioration and act to prevent worsening of the patient's condition. The FCNNs were also able to help their partners develop and hone self-management skills that improved their quality of life. All of the patients in the ESJH FCNN group reported satisfaction with the patient/navigator relationship and found the partnership beneficial. The patients looked forward to the long-term support of their FCNN.
As of May of 2019, approximately 57 patients were part of or had been part of the Faith Community Nurse (FCN) Program with 24 FCNNs. The program has resulted in improved health outcomes for the people in the FCN Program. Specifically, patients in the program have experienced:
A 77% reduction in 30-day hospital readmissions
A 51% reduction in inpatient hospital admissions
A 28% reduction in length of stay when admitted to the hospital
While those statistics are impressive, it is the stories of the patients that speak to the compassionate care DAISY Nurses are known for. Here are the stories of a few patients whose lives were changed by their Faith Community Nurse Navigators.
Mr. A is a patient with a long-standing history of type 2 diabetes and congestive heart failure. Mr. A was on numerous medications prescribed by multiple providers (resulting in improper dosing and poor outcomes), poor living conditions (old house, mold issues), and very little encouragement for a healthy lifestyle by family and friends. In the year prior to starting on the FCN program, he had 6 inpatient hospital admissions and 10 ER visits. Although he had several more inpatient stays in the first 7 months of the FCN program, he has not been readmitted to the hospital in the past 8 months. Terri and Sandra visited him in the hospital during those early admissions then visited him at home when discharged to be sure his needs were met and to help him learn to manage his complex medical conditions. Terri and Sandra were there to compassionately offer support and encouragement when Mr. A was discouraged by his continued poor health. Their holistic care included care of his spirit as well as for his medical conditions. Terri and Sandra worked tirelessly to reconcile his medications and reduce the dangerous polypharmacy related to prescribing by multiple medical providers. They helped him choose healthcare providers from one system so that all of the providers had access to his medical records and could work together to optimize his care. Terri and/or Sandra accompanied him to his appointments to act as his advocate as he transitioned to new providers. They researched living accommodations and as a result, he has moved from his old home to a newer, low-income senior housing project, with a much more positive environment. He credits his FCN Navigator with helping him contact the proper housing authority and move to the healthier home, with reconciling the medication dosages and side effects, with finding healthcare providers more accessible to him (and each other) and improving his activities of daily living (including exercise).
Ms. B is a patient who has lived in a skilled nursing facility for the past couple of years, is bed-bound, and has a history of chronic obstructive pulmonary disease, tracheal stenosis, diabetes, and congestive heart failure. She breathes through a tracheostomy and is unable to care for herself. She gets extremely anxious and fearful and frequently calls 911 from her nursing facility to get the care and attention she believes she needs. In the year prior to starting the FCN program, she had 11 inpatient hospital admissions. Since her enrollment and work with her FCNN, she has had only 1 hospital admission. Ms. B's FCNN visits her in her nursing facility every 2 weeks, providing emotional and spiritual support and encouragement. Ms. B's FCN has become a consistent source of compassionate support and reassurance. The result has been a decrease in anxiety and no more 911 calls. Her FCN Navigator is currently negotiating the donation of a motorized wheelchair that will enable her improved mobility and socialization with other residents. Ms. B credits her FCN Navigator with a substantially improved quality of life.
Ms. C is a patient with very little income, on Medicare, with a history of many admissions to the Emergency Room (ER) due to Lupus-related pain, anxiety disorder, and drug overdoses. Her husband is disabled and also has mental health issues; they have 3 children of high school age. In the year before she began the FCN program, Ms. C was admitted to the ER 24 times and to the hospital as an inpatient 5 times. Since starting with her FCNN, her ER admissions are less than half of the previous year (10) and most of these could have been handled in a clinic visit. She has had 1 inpatient hospital admission for surgical repair of a fistula (appropriate admission). Her FCN has become a consistent source of support and encouragement. The FCN has helped Ms. C develop self-care and coping skills resulting in the resolution of her dangerous drug dependency. She has had no more problems with drug abuse or overdoses. She credits her FCN Navigator with saving her life and "teaching her how to manage her chronic pain without abusing drugs."
Diane Atkinson is a Discharge Planning Coordinator who meets with patients while they are admitted to the hospital and then contacts them after discharge to assess for possible needs after discharge. Diane was making a routine discharge call to Mr. D. Diane's call was disconnected once then went to voice mail when she made an immediate return call. After a few more attempts, Mr. D was able to answer the call. Mr. D told Diane that he had fallen to the floor and was unable to get up. He related that he was not sure how long he had been on the floor and that he did not have his glasses so could not see his cell phone to call for help. Diane stayed on the phone with Mr. D while calling 911 and his son to let him know about the situation. Diane stayed on the phone with Mr. D, offering reassurance, keeping him calm, and informing him of the emergency response until help arrived. She then visited him when he arrived at the hospital. Mr. D credits Diane with saving the day.
These are just a few stories about the impact of the incredible nurses of the Congregational Health Ministries. Terri, Sandra, and Diane have become guiding lights to the people they serve. They are passionate about the mission and truly do provide compassionate, clinically excellent health care in the spirit of loving service to those in need, with special attention to the poor and vulnerable.