Lauren Wilcox

December 5, 2021

NUR 330 Population and Community Health

Population and Community Health Promotion Paper

 The population of people who are readmitted into the hospital because they do not have

the resources they need at home is high. Patients are discharged from the hospital and are sent

home and expected to figure out what to do when they get home so they can prevent themselves

from readmitting into the hospital. Some patients, before they are discharged, get assistance

from social workers or care managers to get some of the supplies they need to continue their care

when they get home. No one is there to follow up with them from the hospital after they are

home to make sure they followed up and are properly using the resources they were given.

Sometimes the patients do what they are supposed to do and follow the instructions the doctor

gives them, as far as medications and follow-up appointments. There are also many instances

where the patients do not follow through with what the doctor has told them either because they

cannot afford to buy their medications or have no way to get to their doctors’ appointments. So

how do we prevent these patients from readmitting to the hospital and make sure they have

everything they need after they are discharged from the hospital? An organization called the

Delaware Care Collaboration has a staff of nurses, case managers, and social workers, to name a

few, that contact the patient after they have been home for a few days to make sure they have

everything they need, from transportation to doctor’s appointments to locations of food banks.

This organization collaborates with doctors and doctor’s offices that are willing to participate

with them, mostly doctors who are associated with St. Francis Hospital. The staff of nurses

makes calls to each patient at least weekly, sometimes even daily, to assess the patient’s needs

and see how they are doing. From this point, the nurse either goes about doing things for the

patient themselves or they collaborate with social workers or community health workers to find

more resources they can give the patient to help them get the care they need.
 The patients of these nurses have a variety of needs and some are so simple that they are

taken advantage of, but for some people they are not so easy to get. When the nurses call, they

talk to the patient about how they have been and if they have ben compliant with their

medications. After talking to the patient for a while, the nurse finds out what needs the patient

has and tries to fulfill any way they can. During my shadowing time, the nurse I was following

helped patients find COVID testing sites and vaccine sites, weekly food banks, collaborated with

the social worker for ways in which the patients can get transportation to and from their homes,

helped patients find apartments that they could stay in because they could not afford their current

homes, and many other things. We made calls to doctor’s offices, social workers, community

health workers, and many other people to help these patients in the best way we could. We also

attended Zoom meetings of doctors giving presentations about different medical topics, all of

which can help the nurses better their patient care and to give them other ways they can find

assistance for their patients.

I believe the work that the Delaware Care Collaboration is doing is helping a lot of

patients. The only down side to this is that this organization is only in collaboration with St.

Francis Hospital and the doctor’s that are associated with this hospital. There are many other

patients at hospitals, such as Christiana and Bayhealth, that are not receiving this specialized care

and are being readmitted into the hospital because they cannot afford their medications or cannot

get to their doctor’s appointments to get their medications. This organization should be available

through all hospitals, whether it is a state run organization or each hospital has their own Care

Collaboration. These organizations have shown to prevent hospital readmissions and better

patient outcomes. If there are doctors willing to participate, whether they are associated with a

hospital or they have a practice of their own, there should be ways in which they can participate
with an organization that can help their patients after they leave the hospital, when they no

longer have the resources they had in the hospital. Overall, the Delaware Care Collaboration has

helped many patients in the past and continue to help them every day. From food banks to new

apartments, these nurses and care workers are there to help the patients no matter what within

their realm of abilities. I believe that all hospitals should have some kind of organization like

this that doctors can be a part of and patients can get the best care.