The Next Thirty Days

Baptist Easley Hospital sees individual successes with new focus on Transitions Care

Hospitals work hard to provide the best possible care to their patients, but it’s often the life the patient leads between visits which ultimately determines their health outcome.


Take Forrest “Scott” Poole. When he checked in to Baptist Easley Hospital this past March, to say he wasn’t in great shape would be an understatement. Suffering from acute congestive heart failure and alcohol abuse, he had gotten to the point where he could not sit himself up and was forced to crawl up the stairs to bed.


“I was [pretty much] confined to my bedroom for three weeks,” he recalls. “I didn’t know if I would ever recover.”


 Poole spent four nights in the hospital before being discharged. But his story doesn’t end there.


Thanks to the care and attention, he received, particularly from his team of nurses, Poole was able to turn his home and life around.


“They kept me upbeat—were never in a bad mood,” says the former patient, who cites them along with his mother and God as inspiring him to strive towards recovery. “They gave me strength.”


And while the care in the hospital played a central role, it was in part the diligent follow-ups from the hospital team, and home health agency that kept pushing Poole forward.


Their approach was part of a new commitment by South Carolina hospitals to support more expansive and non-traditional methods of care. By moving away from a fee-for-service model to a fee-for-value one, hospitals are changing their business models as a way to both cut costs and improve patient outcomes. Baptist Easley was one of six hospitals in the state to receive The Duke Endowment Care Transition Grant to jumpstart this kind of transition, leading to a new system of care which pays attention to not only physical health, but psychosocial health as well.


Because Poole was tagged as a high-risk for readmission patient, a care transitions nurse from Baptist Easley conducted a home visit a few days after his discharge. His house and living conditions were still in complete disarray, and he did not understand his diagnosis, so she straightforwardly explained to him what needed to change, everything from his diet and exercise to changing habits and monitoring his blood pressure.  She called him weekly after his discharge and received updates on his progress.  Poole took it to heart, made changes, and even invited her back four weeks after his hospital discharge to see what he had accomplished.


Throughout the month after discharge, he was also visited by a home health nurse and physical therapist from Greenville Health System Home Health.  Scott recognizes having someone to talk to and people who were able to help him better understand his condition has helped him tremendously on this journey.


A critical part of the transitions of care initiative that Baptist Easley has focused on, has been a collaborative effort with community partners such as home health and skilled nursing.  These efforts have improved the gaps in care identified when patients transition out of the hospital to post acute care services.


“He has cleaned up that house into an immaculate home, quit drinking alcohol, was reading labels and making homemade low-salt meals, doing a lot of exercise, doing everything he can to improve his health,” says the care transitions nurse who cared for Poole. “He has a really positive outlook on life and on being a good dad for his children. He has encouraged me more than I can tell you.”


She cites teamwork between herself and her co-workers as “pivotal” to the process and heaps praise on Poole himself. 


“When it all comes down to it, with all that we all try to do to help our patients get better, it’s the patient who has to make the lifestyle changes and do the hard work, and Scott did it,” she points out. “He not only agreed to be mentioned by name but offered to come speak by way of encouragement to anyone whom he might help through his experience.” 


The ripple effect of one transformed life affects so many.  It is patients like Scott who inspire the health care team to think big, visualize the impossible, and work harder to help patients realize their potential.  Scott, for his part, offered to let his name and story be told and is willing to speak to others by way of encouraging them.  His believe is as he put it, “If I can do it, so can anyone else.” He would like to help others in situations similar to his by passing on what he’s learned, and the healthcare team is blessed to have learned a lot from him.