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Virtual Case Managers Add Detective Presence That Helps Keep Older Adults Out of Hospital

Julie Hontz

You don’t know what you don’t know. Julie Hontz is very aware of that.

She is a virtual case manager for Penn Medicine at Home's SOAR, which is based in the Hospital of the University Pennsylvania (HUP). SOAR, which stands for Supporting Older Adults at Risk, is a program that works to help elderly patients go home from the hospital earlier through the assessment of needs and providing support in the home. Hontz’s role is to make calls with the patients and caretakers to sniff out any issues before they become impediments to healing at home. It’s a role that was added just a year ago to the program, but it has already proven vital.

“Without Julie, it’s very unlikely that we’d know about many of the issues that have occurred in our geriatric patient population,” said Rebecca Trotta, PhD, RN, director of Geriatric Nursing and head of the SOAR program. “Adding her role has been one of the biggest and most important changes made in SOAR since we launched.”

Earlier this year, Hontz connected with Hugh Logan, a patient with heart failure. After a stay at a different local hospital for sepsis and pneumonia — the danger for both being amplified by heart failure — Logan went to the HUP emergency department for help several days later, which happened to be New Year’s Day.

Once it was deemed safe, Logan was enrolled in the SOAR program to help manage his complex condition and sent home. Hontz gave him regular check-in calls to make sure he was doing well. During one call, an issue that had never come up before made its way into the conversation: both Logan’s refrigerator and microwave were broken.

“That made it difficult to for him to maintain the right diet for someone with his condition because he didn’t have the means to store or prepare healthier food,” Hontz said. “He shared with me that he was only eating canned foods as a result.”

Knowing that patients like Logan are twice as likely to be readmitted to the hospital because of malnutrition, Hontz took immediate action. She not only ordered a new refrigerator and microwave, but also arranged for the removal of the old fridge to make room for the new one.

Those small steps made it possible for the SOAR program to then get Logan connected with MANNA, a community agency that the program has partnered with, which provides free, heart failure-friendly meals.

Without such an experienced case manager so focused on the geriatric program and familiar with common problems among that population, these types of issues might not have been noticed in the past, and Logan may have been forced to return to the hospital

The virtual case manager is, of course, just one member of the SOAR team dedicated to keeping Logan and other geriatric patients with unique stories of their own safe — and happy — at home. For instance, while Logan was in the hospital, student geriatric consultants and nurse geriatric consultants, who do assessments to determine the needs of the patient, took him for walks to promote mobility, helped him with feeding to keep his nutrition up, and even played games with him to keep him cognitively engaged and prevent the delirium that can often set older patients back in their recovery.

And once he was home (through SOAR-provided transportation), he already had his medications through the SOAR team’s help, along with a free case of nutritional shakes.

“The SOAR team members were invaluable to my recovery,” Logan reflected. “I have been very lucky to be their patient and receive home care. I can’t imagine other patients who are left on their own.”

Months after his hospitalization, Logan remains on the path to recovery. In addition to MANNA, he receives meal support from Meals on Wheels, but he’s also trying to make meals independently.

“I’ve been making myself peanut butter and jelly sandwiches,” Logan explained. “They are pretty good!”

Many patients, like Logan, have had pivotal and sometimes even life-saving experiences with the SOAR program. While the program has many merits, perhaps the greatest benefit to SOAR patients is the connection and support they receive from health care providers on the SOAR team, like Hontz. As Logan notes, “They are the real medicine.”


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