UAH’s nursing outreach program a benefit to all

UAH Nursing

UAH's CHEERS project pairs nursing students with patients in medically underserved communities throughout Northern Alabama.


When a patient is readmitted to the hospital within 30 days of discharge because they failed to receive adequate care, it's known as an avoidable readmission. And unfortunately it happens more frequently than it should, particularly among medically underserved populations like the elderly and those who live in rural areas.

"Many of these patients are eligible for transition services, but if the referral is not made prior to discharge, they don't even know to ask about them," says Maria Steele, a clinical assistant professor in the College of Nursing at The University of Alabama in Huntsville (UAH). "Then they fall through the cracks and have to manage on their own, and it's not the optimal outcome."

So to combat the trend, the Centers for Medicare & Medicaid Services (CMS) recently launched a new initiative under the Affordable Care Act called the Community-based Care Transitions Program (CCTP). Its goal is to facilitate the coordination of community partners to improve the care patients receive as they transition from the hospital to their homes.

Among the organizations selected to participate in the program is Huntsville-based Top of Alabama Regional Council of Governments (TARCOG), the region's designated Area Agency on Aging. And assisting with this endeavor is UAH's College of Nursing, a longtime TARCOG partner through its Coalition for Health Enhancement of Elders and Referral Services (CHEERS) project.

North Alabama MUA Map

North Alabama counties represented by TARCOG.

Data: HRSA

"I teach a course called 'Caring for Families, Aggregates, and Populations: Theoretical Applications' and CHEERS is an option for the clinical requirement," says Steele. "Its purpose is to provide a community education experience for registered nurses enrolled in UAH's RN to BSN program, so when TARCOG was selected for the CCTP, we teamed up to focus on medically underserved populations in the Huntsville area."

It starts with the CCTP coach, whose job is to coordinate the patient's care services as they transition from the hospital to their home. That can include rehabilitative care, mental health and social services, and in the case of UAH's CHEERS project, regular in-home visits by a registered nurse.

"The coach tells the patient about our program and asks if they would like an RN to come visit them for eight weeks and help with health assessment," says Steele. "If the patient agrees, our student contacts them to set up the first home visit, where they establish a rapport with the patient and caregiver and get a thorough history of their illness."

At that point, the student will also develop a teaching plan that identifies the patient's main risks. "We focus a lot on risks in the home – fall prevention, and medication safety and compliance," she says. "So if, for example, a patient has been prescribed a new medication, they might need additional information about its side effects and complications, as well as reinforcement on how to take it."

The teaching plan is then executed over the next two months, with the student visiting weekly and Steele herself visiting at least once to ensure the program is on track. "I make sure the student is following the objectives of the course and answer any questions," she says. One thing neither she nor the students do, however, is perform invasive procedures. "It's strictly assessment, teaching, and providing further referrals if needed."

That individualized, patient-centered care can make the difference between a hospital readmission and being in your home.

Maria Steele
Clinical Assistant Professor

On rare occasions, Steele has had to reassign students whose patients either opted out or were rehospitalized. But most are able to successfully complete the assignment – and in the process learn firsthand the challenges that medically underserved patients face. Steele says she's received feedback from many of her CHEERS students about just how "eye-opening" the experience is.

"It broadens their understanding of different problems in the community, and it makes them more knowledgeable about what services would be helpful in the home for elderly patients or patients in rural areas," she says. And as for the patients themselves? "Hopefully, at the end, they are more knowledgeable about self-care management of their illness."

That may not sound like a lot, but to the people who receive these services – particularly those not eligible for home health care – it's invaluable. "Getting our skilled nurses into the community ensures that there's continuity of care that extends into the home," says Steele. "That can make the difference between a patient being readmitted to the hospital and being in their home."

Indeed, there's already evidence that initiatives like the CCTP are working; the CMS's most recent report on readmission rates shows an unprecedented drop. And no doubt that will continue to be the case as this latest crop of more-informed nurses enters the healthcare workforce. "Many will work in a hospital setting," says Steele, "but this experience will make them better advocates for everyone."