The patient had never been sick enough to have any real experience with medicines.

She had Medicare coverage, but no prescription medication plan. She didn't even have a doctor.

Last fall, the Moore County retiree had a heart attack. Just a few days after she left the hospital, she was back with congestive heart failure, something that often happens when a patient doesn't understand how to manage a medical condition.

Fortunately, the patient says, FirstHealth's Community Case Management Program was available to provide help "in so many ways."

Since it was started last fall, the Community Case Management Program has helped more than 30 people with a chronic disease such as congestive heart failure, uncontrolled high blood pressure, chronic obstructive pulmonary disease, atrial fibrillation and diabetes.

Funded by the Foundation of FirstHealth, the program is open to eligible patients who live within a 30-mile radius of FirstHealth Moore Regional Hospital, an area that includes all or parts of Moore, Montgomery, Richmond, Scotland and Lee counties.

Services include:

n Scheduled follow-up phone calls -- made by trained volunteers -- that are based on questionnaires tailored to each patient's diagnosis

n Referral, when needed, for medical care

n Medication management and/or help getting medications

n Community resource referral

n Health-related education

n Assistance with transportation to and from medical appointments

n Telehealth services for at-risk patients

Targeted patients have had three or more admissions to the hospital for the same diagnosis within the previous six months, can't afford their medications, need help with medication management, have limited financial resources or have a medical condition that could result in a high hospital readmission rate if not managed.

According to Deborah DeLong, administrative director of Moore Regional's Hospitalist Service, the Community Case Manage-ment Program serves patients who are frequently hospitalized due to chronic disease.

"The goal is to have better outcomes and reduced hospital readmissions," she says.

'Safety Net of Care'

Although funded by the foundation, the Community Case Management Program reports through the Hospitalist Service program, because so many of its referrals come from those providers.

Hospitalists are specially trained health-care providers -- physicians, physician assistants and nurses -- who treat patients only in the hospital and do not work in outside medical practices. The staff includes a nurse coordinator as well as the trained volunteers.

For several months, the coordinator has been Heather Taylor, a nurse practitioner with a background in adult health.

She calls the program "a safety net of care," a potential lifesaver for patients who may be taking 20-plus medications and who often need direction on when and how to take them.

"Education is a large component of the program," she says.

The program relies on the volunteers who make the phone calls to patients who are assigned specifically to them.

A comfortable rapport can develop as a result, often allowing the patient to be more open with his/her assigned volunteer than with other medical contacts.

Calls are made according to a regular schedule: daily for the first week after a patient leaves the hospital, every other day during the second week, as needed for a period of time to be determined according to the patient's needs, and then monthly.

Questions are tailored to the patient's specific condition.

"That's one of the things that make us unique -- that the questionnaire is tied to the patient's needs," Taylor says.

A patient with congestive heart failure might, for example, be asked questions related to weight gain: Have you gained 3 pounds in 24 hours? Or 5 pounds in a week? An answer of "yes" to either question would trigger a call to the program coordinator.

Terry Riddle has been a Community Case Management volunteer since the program started.

A former Marine and District of Columbia police officer, he worked in customer support for AOL Call Centers in Virginia before retiring to Moore County.

He also volunteers with the AARP, preparing tax returns for senior citizens in an AARP/IRS joint venture at the Moore County Senior Enrichment Center, so he has lots of experience at asking questions and listening to answers.

The questions he poses to Community Case Management patients cover a wide range of information. But, he points out, the greatest challenges usually involve medication changes and determining who made those changes and why.

"Sometimes it's like you're playing private investigator," he says.

Making it Conversational

Another challenge involves keeping the questions conversational.

"Otherwise, you become more of a solicitor than someone who cares," he says.

If a patient's response to a question alerts the volunteer to a possible problem, the nurse coordinator is informed and, with physician input, decides how to follow up.

"The patient would be referred to the appropriate venue, the ER or an evaluation coordinated with the primary care provider," Taylor says.

Provider contact is essential to the program's success. "The primary care provider is pivotal to the success of the program, because it's a collaborative approach," says DeLong. "We're looking at the whole patient."

The success of the FirstHealth Community Case Management Program was recognized during a poster presentation at the Society of Hospital Medicine's annual conference in San Diego in April.

Titled "Bridging the Health Care Gap: An Effective Collaboration of Hospital Medicine and Community Care Management," the poster highlighted the efforts of Moore Regional Hospital's Hospitalist Service and the FirstHealth Community Care Management Program to provide care to high-risk patients with chronic diseases.

The poster was prepared by nurse practitioner Heather Taylor, Community Case Management Program coordinator, and presented by Dr. Jenifir Bruno, assistant medical director of the MRH Hospitalist Service.

The Community Case Management Program is a part of the Foundation of FirstHealth's Hospitality Services Program.

The program is free, but eligibility is based on established admission criteria. Referrals can be made by physicians, nurses, case managers, support staff, friends or family members. For more information, call the program coordinator at (910) 715-1275.