What We Tried

We started our Community Health Department in August 2013 with one nurse leader, and the department has grown significantly from there. Our focus is two-fold: community education/engagement and in-hospital care coordination services leading to a safe and effective transition home.

From the community education and engagement perspective, we lead a community-based DSHS (Texas Department of State Health Services) grant and corresponding health care coalition. The grant is focused on reducing avoidable hospital readmissions through care coordination, community education and health care provider education. The Ector County Health Care Coalition is composed of key community members representing education, public and private sectors, and nonprofit agencies as well as other leaders with an interest in improving the health of our community. The coalition’s focus is to provide an abundance of community education and thus create engagement across various public sectors. Additionally, all members of the coalition are able to refer residents to the many services available through the hospital’s Community Health Department.

We also created the Faith & Health Network, led by a nurse navigator, which partners with several dozen local congregations of various denominations. Through this network, we involve congregation members in health promotion events, including health fairs, walking clubs, health challenges, public lectures, individual health screenings and counseling, and a “drive-through” blood pressure clinic. To date, more than 2,000 individuals have joined the Faith & Health Network and benefited from these health promotion events.

At the hospital, we now have an interprofessional team of 27 health care professionals, including nurses, respiratory therapists and social workers. Our services reach thousands of patients each year. To date, we have helped more than 14,000 patients transition safely into the community and enjoy healthier lives. We created a care coordination model comprised of four key team members per patient care unit: two inpatient care coordinator nurses, one social worker or care transition coordinator, and one community nurse navigator.

Working with physicians, patients, family members and other key health care team members, we have redesigned care coordination and discharge planning for our patients. Patients in the hospital are thoroughly assessed after admission, and individualized care plans are developed to meet medical, social, financial and physical needs. At daily care briefings, team members discuss any care concerns and plan for safe and timely patient discharge. They connect patients with the necessary resources to transition safely back into the community setting. Our team works with physical therapists, dieticians, physicians, speech therapists and others to meet the complex medical needs of our patient population.

Upon discharge, patients are transitioned to the care of a community nurse navigator. The navigators form close relationships with patients and can follow them for weeks and months–and years, if necessary. Navigators help patients meet their medical needs while simultaneously addressing determinants of health that may be impeding the patient from living a healthy lifestyle. Our teams have successfully helped county residents access consistent transportation, meals, jobs, housing and funding sources.