Avera Medical Minute: Care Transitions Program

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Dan Barton is thankful for the care during a recent stay in the hospital being treated for Chronic Obstructive Pulmonary Disease or COPD, but he'd rather not go back. He has more fun things he'd like to do.

Avera care transitions

"Friday I'm going fishing for a week, and I already made plans with one of my friends to go duck hunting, so I got stuff to do," said Barton.

Since being released from the hospital, Dan has found a new tool in managing his care. "At Care transitions they get you straightened out, making sure you're taking things the way they should be. I was doing an inhaler before and I wasn't doing it correctly, so they showed you how to do it, a good deal," said Barton.

The Care transitions program was born out of need. The Avera team was aware that the highest rate of patients being re-admitted were those with COPD or congestive heart failure, so they created this free service to follow up with patients and hopefully keep them healthy at home.

Avera coordinator of pulmonary education Char Raley describes the valuable program. "A nurse goes into the patient's home when they have COPD, and then that nurse then goes over all of their medications with them, and then she goes ahead and logs onto a computer, via our telehealth, she pulls me up on a screen," says Raley.

That connection allows Char to go over the instructions, and make sure medication is being used properly. "We'll ask the patient how he's taking it, and if it's an inhaler or something that requires them to do a demonstration, we actually ask them to demonstrate," says Raley.

Dan says if he has symptoms developing, he knows that team at Care transitions is just a call away.

"You know who you can call if something isn't going right, otherwise you know trying to get into pulmonary, sometimes it takes a while," said Barton.

Knowing that medications for COPD or Congestive Heart failure can be expensive, the team also researches what medications are possible, their cost, and any other possible less expensive alternatives.