CHI - Mercy Hospital Valley City

Teaming Up for Transitioning home after illness or injury takes a team and involves care for the whole person. The Swing Bed program at CHI Mercy Health coordinates care for patients who need a home away from home as they recover and make decisions about their future care needs. Some patients go on to long-term care facilities; others gain skills to transition back to home; still others choose to obtain their end-of-life care here before they move to their eternal home. Naomi Koch, MS, Director of Case Management at CHI Mercy Health, directs patients through the admission process and acts as a guide for them during their stay in the Swing Bed program. "My job is to empower people to make their own health decisions and educate them on their options," Naomi says. "I'm here to help patients overcome obstacles and find creative solutions and solid supports for life after Swing Bed." To do so, she co-leads the discharge planning team alongside Carla Bata, RN, MSN, Medical Surgical Unit Manager, CHI Mercy Health. "Naomi and I meet every weekday with our multidisciplinary team, which includes Physical Therapy, Occupational Therapy, Respiratory Therapy, Nutrition Services, nursing support, and spiritual support," Carla says. "We want to know how each patient is doing at every stage of care and what they need to achieve their remaining goals." POWER OF PERSPECTIVE During meetings, a member from every discipline shares, so no angle is left unexplored, says Donna Smith, MS, OTR/L, Rehabilitation Manager, CHI Mercy Health. "For instance, if I'm working on activities of daily living with someone, I'll report on their progress and what they need to accomplish before they are ready for a safe return home," Donna says. "Physical therapy reports on their balance and coordination progress, nurses share lab reports, and our dietitian shares information about food intake. After 20 minutes, we have a full picture to work with and make decisions from until the next meeting." Donna acts as the sole occupational therapist and oversees three physical therapists, including Kyle Gregerson, PT, DPT, who states, "We work with patients recovering from strokes, joint replacements, surgeries after broken bones, widespread infections, or any other health conditions that make it difficult to return home safely after their initial hospital stay. We listen to their goals and take into account what their home needs are to improve their overall mobility and decrease their fall risk." Swing Bed Care CHI Mercy Health Nutrition Services team members include (from left): Anna Carlson, Dietitian; Ellen "Toots" Coghlan, Cook; Teresa Garrahy, Nutrition Services Manager; Sue Skarloken, Cook; and Diane Merkes, Cook. CATHOLIC HEALTH INITIATIVES /// www.mercyhospitalvalleycity.org 2

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