Coordinated Care regimen at SPHP helping patients heal faster

January 08, 2019 06:32 PM

Getting patients out of the hospital faster and on the right track for recovery more quickly. That's at the heart of a nationally recognized program offered by St. Peter's Health Partners.

It's challenging for patients to wend their way through the health system -- especially if they need ongoing care. That's where the Integrated Care Coordination System comes into play at St. Peter's Health Partners.


A Loudonville woman shared her story of how this has literally helped her get back on her feet.

Although she's still needs help walking, the fact that Sylvia Ellis is walking is a testament to her will, and the therapy she's gotten since a devastating car accident in June, 2017.

On her way to work at Ichabod Crane High School, her car was hit and her life spun out of control.

"You would have seen a person in a wheelchair who definitely wanted to get out of the wheelchair," she explained.

Paralyzed from the waist down, Ellis needed an extensive array of services to recover and walk again. Her care plan was mapped out by the St. Peter's Integrated Care Coordination System. It's one of only two such comprehensive programs nationwide to earn certification from a national accrediting organization.

Accolades aside, it's essential for the patient and their family.

"So we have a group of registered nurses who accept a referral and then we take it from there. We guide the transition from a hospital to the best level of care for that individual to meet his or her needs," explained Kim Baker, the president of continuing care at St. Peter's Health Partners.

By organizing care, patients can get back home more quickly - reducing the risk of a hospital acquired infection and improving their overall outlook - both facilitating recovery.

The care continues once they're home.

"A month whereby some people came to the house and worked with me. They were from various Eddy institutions. Then, I resumed work here at Sunnyview Rehab," said Ellis.

Ellis is one of 16,000 people in the Continuing Care Network on a daily basis.

Now that the Integrated Care Coordination System is literally on its feet, they're looking to move into phase two. That would include more of the same St. Peter's Health Partner facilities – and also expanding into behavioral health.

As for Ellis - she figures she's about 80 percent recovered.

"I'm a former teacher, so that I know that's not Regent's mastery yet, but I'm working towards Regents mastery and I want to have it happen," said Ellis.

With her care team, she can look forward to that milestone.

The bottom line to the program -- as Baker points out, is getting people to the right level of care at the least cost. Getting it done in the parlance of the day.


Benita Zahn

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