Breaking down barriers to a safe hospital discharge through a new community partnership and Hospital to Home program

New program one way UCHealth is partnering with community agencies to reduce health care costs and readmission rates.
January 10th, 2020

Through an innovative partnership between UCHealth Memorial Hospital and The Independence Center, people like Steve Frost and Sean McCullough are home, sleeping in their own beds at night.

Hospital to home program participant at his trailer home in Colorado Springs.
Steve Frost said he’s grateful for the Hospital to Home program because it helped him to get home after a long hospital stay at UCHealth Memorial Hospital. Photos by UCHealth

While there’s nothing like sleeping in your own bed, and no place like home, the partnership is one of the ways that UCHealth is partnering with community agencies to provide innovative ways to reduce health care costs, readmission rates and ease capacity issues in hospitals by making beds available for the acutely ill. Through the Hospital to Home program, created by the two agencies, patients – and the health care system – fare better.

When you can’t return home after hospitalization

In the Spring of 2018, Steve Frost had an epileptic seizure while driving. He went to Memorial Hospital Central, spent three months there, got out, had another seizure a month later and was back in the hospital for three more months. During his second stay, squatters broke into his modest, one-bedroom mobile home in Fountain and trashed the place. When a social worker checked to make sure the residence was safe, she found disaster. Frost, who was medically fit to leave the hospital, had nowhere to go.

Needing extra help to return home from the hospital

Sean McCullough found himself in a similar dilemma, though the circumstances of his hardship are different. McCullough, who is obese, fell in his three-story Colorado Springs apartment and was unable to get up. The Colorado Springs Fire Department placed him on a “toboggan’’ type of device, slid him down three flights of stairs, got him into an ambulance and took him to Memorial. Doctors performed surgery on McCullough’s shoulder, and he spent two weeks in the hospital. Fire Department paramedics said McCullough should not return home because of holes in the floor of his home. They deemed it unsafe.

McCullough was sent to a rehabilitation hospital for two weeks and then to a long-term care facility for 100 days. Before he left Memorial Hospital, he was introduced to Mandi Strantz, transition coordinator for the Hospital to Home program. Strantz worked to repair the holes in the floor at McCullough’s home, which he shares with his mother, and to provide a Hoyer lift and a trapeze – equipment that will help McCullough get up and out of bed. Strantz is also working to provide home health care to help McCullough with daily needs and physical therapy.

Because of his extreme weight, McCullough has not been on his feet since Aug. 26, 2018.

“I would be dead without them,’’ McCullough said of the partnership with The Independence Center. “Without their help, especially Mandi’s help, without her Herculean efforts on my behalf, I wouldn’t be able to do this. I would have managed to walk long enough to jump off the third floor or something. But with her, I am hopeful of getting back on my feet.’’

Two agencies come together to create Hospital to Home program

Strantz’s position is paid for by the partnership with UCHealth, a $120,000 award from the Memorial Hospital Foundation. Services include meals in the home, transportation, setting up home health care, occupational therapy, physical therapy, respiratory therapy, setting up homemaking services like housekeeping and grocery pickup, receiving and setting up durable medical equipment and helping with medication delivery and funding. Social workers call on The Independence Center when a patient is medically ready to go home, but can’t because of social determinants.  The Independence Center provides case management and resources to improve living conditions that help to keep patients out of the hospital.

“This is a way that we can extend our care and serve the community,’’ said Joe Foecking, director of the inpatient rehabilitation care unit at Memorial Hospital Central. Foecking also serves as chairman of the board of The Independence Center. He presented the pilot program to Memorial leaders who recognized how it would improve patients’ lives.

“This is a clever program, and shows how we’re seeking ways to help people and reduce costs at the same time,’’ Foecking said. “We are freeing up resources for other people in our community who are acutely ill and need a hospital bed, and we are accommodating individuals in a most humanitarian way.

“This lessens the cost of health care, serves the community and these individuals don’t want to be here in the hospital, they want to be home,’’ Foecking said.

Avoiding skilled nursing facilities after hospitalization

Steve Frost agrees. When vagrants broke into his mobile home, he had already spent months in the hospital. Frost has had pancreatic cancer, multiple fractures in his back and severe epileptic seizures. He didn’t want to go to a skilled nursing facility upon his release from the hospital. With a little help, he’s able to be home.

“I like my privacy,’’ he said. “It’s hard to say where I would be. They were just a saving grace sent by God, literally. Mandi, she was an angel when she came in the room that morning because I didn’t know what I was going to do. They were telling me that I couldn’t come home because I couldn’t take care of myself.’’

Strantz worked with another organization in Colorado Springs to help rebuild a shower in Frost’s home, through a long-term Medicaid waiver, making his ability to shower on his own possible. The Independence Center also sends helpers who go to the grocery store for Frost and prepare meals that he is able to heat up.

“I have multiple fractures in my back and just the ride to the store is painful. I feel every bump,’’ he said.

When he came to Memorial the first time, he said, “I was really skinny, I just couldn’t stand up.’’

former patient and Hospital to Home program employee talk at trailer home in Colorado Springs.
Steve Frost talks to Mandi Strantz from the Independence Center in Colorado Springs about his needs. Strantz is instrumental in coordinating services that help Frost live comfortably in his Fountain home.

“He has pain standing in the kitchen,’’ Strantz said, “so the caregivers prep meals for him.’’

Frost, who is covered by Medicare and Medicaid, is appreciative of the “good hearty meals’’ that are prepared for him.

Transitioning people from the hospital to their home

Patricia Yeager, CEO of The Independence Center, said: “We’ve set out to prove we can transition people with disabilities out of the hospital to home after an acute episode rather than a nursing home.

“There’s a lot of research around ‘Why doesn’t health care work?’’’ Yeager said. “And, usually it’s social determinants of health, like housing, having a job, having transportation, food, security and all of those kinds of things. So that’s our specialty, the social determinants of health.’’

Strantz said the patients that she helps are often referred to her by discharge planners who work at the hospital.

“If there are barriers to a safe discharge, then they’ll reach out to me and we see if we are able to help out. In Steve’s case, the planner talked to him and then reached out to me,’’ Strantz said.

Low-cost assistance after hospitalization

Frost said the program has made a huge difference in his life.

“They got me home. Now that I can’t drive or anything, I’m dependent on them,’’ he said. “So, there’s always some paperwork to fill out, or if I need to go somewhere or something, Mandi makes it happen.’’

Frost has had hernia surgery and gallbladder removal surgery in the past year, but he has not been readmitted to the hospital after each event because of the low-cost assistance provided through Home to Health and other community programs.

McCullough said the Hospital to Home program has also made the difference for him. Strantz helped facilitate the repairs on the floor in his home, get him a new bed and equipment. She is working on a plan to send caregivers into McCullough’s home to help him with daily living and getting back on his feet. Prior to his trip to Memorial, caregivers would not go to his home because of unsafe conditions with the floor.

“I was in pretty bad shape by the time all of this passed,’’ McCullough said. “This particular incident, my life had been pretty scary for the month prior to this going on because I couldn’t reliably even make it to the bathroom.’’

He said his shoulders were injured “in the process of trying to keep me from falling.’’

There is no place like home

Being home and having a new bed, he said, has been a godsend. Even though he has not been out of bed and relies on urinals and bed pads, he’d rather be home than anywhere.

“I have my mom here to talk to and my friends know where I am,’’ he said. “I have my cat, although today, we are miffed at him. The first thing he did today was bite my mom. He’s a 19-year-old cat, though, so we have to give him some slack.’’

McCullough said Strantz helps to bring him supplies and fill out paperwork needed to receive community-based services. He said that because he is so overweight, he is used to being refused services.

“There’s a lot of ‘oh my God, I don’t know if we can help him,’ which is something that I am used to,’’ he said.

McCullough said that with help, he is hopeful to get home health care back into his home. He’d also like to have physical therapy and help with daily living tasks.

“In the longer term, I’d like to get back on my feet with the help of maybe a cane or a walker,’’ he said.

Through the Hospital to Home partnership, dozens of people will be helped – people like Frost and McCullough who, like anyone else, just want to be home.

About the author

Erin Emery is editor of UCHealth Today, a hub for medical news, inspiring patient stories and tips for healthy living. Erin spent years as a reporter for The Denver Post, Colorado Springs Gazette and Colorado Springs Sun. She was part of a team of Denver Post reporters who won the 2000 Pulitzer Prize for breaking news reporting.

Erin joined UCHealth in 2008, and she is awed by the strength of patients and their stories.