Man From Guatemala Goes Home

When a patient discharge gets tough, our complex discharge team gets to work to discover creative solutions that help us do the right thing for our patients and for OhioHealth.

At OhioHealth Grant Medical Center, more than 20 social workers mobilize regularly as part of a comprehensive care management team. These social workers ensure patient and family wishes are heard, respected and carried out to the best of their ability.

The new complex discharge team acts as a subsegment of that powerhouse group, helping reduce total cost and hardship to patients upon discharge. Modeled after similar teams at Northwestern University and the University of Michigan, the team employs one full-time social worker who focuses on one complex discharge case at a time, which enables the social worker to devote their undivided attention to the patient.

Lisa Applegate-Lewis, a seasoned social worker in the OhioHealth system was selected by a steering committee at Grant for this specialized role in February 2018.

Applegate-Lewis hit the ground running. She was poised and ready for the challenge of her first case – one that had global implications.

The case: A Guatemalan man living in Ohio suffered a traumatic brain injury requiring 24/7 supervision. After several months at Grant, the patient wanted – and needed – to get back to his home country for continued care. But the costs for medical transport to Guatemala exceeded $20,000.

Applegate-Lewis sprang into action, unwilling to accept such an expense for the patient or the system. It was already costing thousands of dollars a day to keep him hospitalized, so she knew she needed to move quickly.

Applegate-Lewis began connecting the dots of the patient's story, trying to find a solution. She overcame language, geographical and financial barriers along the way.

"When a patient is visiting from another country, it takes a lot of work to figure out who's where," said Applegate-Lewis. "And since he didn't speak English, it took extra care to make sure we understood what he really wanted."

Although the patient had a handful of friends and family in the United States, they were unable to provide the intensive care he needed. It was clear he needed to go home to his family in Guatemala, but he couldn't fly by himself. Applegate-Lewis searched high and low for affordable medical transport options, but none could deliver the 24/7 supervision the patient needed.

Just when things looked especially grim, Applegate-Lewis landed an appointment with the patient's pastor in Cincinnati.

Expressing deep compassion for the patient, the Hispanic, multilingual pastor partnered with Applegate-Lewis to find the patient's family in Guatemala where he also had extended family.

"He even taught me a little Spanish," said Applegate-Lewis.

Applegate-Lewis finally found a significantly more affordable flight, and the pastor offered to accompany the patient back home to Guatemala and deliver him safely to his family.

Caring for a member of his flock and getting to visit his own family made the trip a double blessing for the pastor.

"Our staff was in tears," says Tricia Mills, Applegate-Lewis' manager. "Seeing someone's pastor – or anyone – step up like that is just unheard of."

Mills applauds Applegate-Lewis' creativity and resourcefulness, and her willingness to think outside the box for solutions.

"Lisa is known for using her experience to shepherd newer social workers and encourage deeper collaboration with ethics and legal teams," she said.

Volume to Value, One Patient at a Time

The complex discharge team at Grant upholds Our Value Journey by redefining our care and payment models in even the most complex discharge cases.

"We just can't live within the walls of our facilities anymore," said Mills. "The shift from volume to value means we have to be willing to stay nimble and work differently."

As healthcare becomes increasingly confusing, stressful and expensive, Mills and her team believe it's part of their role to create simplicity to better serve our patients and their families.

But the benefits of Applegate-Lewis' actions transcended finances to benefit the patient's caregiver team as well. After the patient's successful discharge, Applegate-Lewis and Mills hosted a Schwartz Round to help the patient's bedside team debrief about their experiences. In these powerful sessions, caregiver associates have an opportunity to share their experiences, thoughts and feelings drawn from actual patient cases.

We believe caregivers are better able to make personal connections with patients and colleagues when they have greater insight into their own responses and feelings. Applegate-Lewis' first case as the complex discharge team social worker impacted the lives of so many.

Associates like Applegate-Lewis and Mills are helping us make the critical shift from volume to value, one patient at a time. On behalf of the entire system, thank you for your commitment to doing the right thing for patients and the smart thing for OhioHealth.

This story was originally published in an internal OhioHealth associate publication.