The Bridge Services department at Sierra View Medical Center seeks to be
a connecting department for patients to help them from the point of discharge
to enjoying health at home. The Bridge Services Department, once part
of Care Continuum, is newly named and redesigned to specifically focus
on outpatient care management and offers two key programs:
PACT Program: Post Acute Care Transitions for CHF, COPD and PNA patients.
Palliative Care
The Interdisciplinary Team includes:
Devon Barlow-Merritt, MHL, BSN, CCM (Program Manager and RN Case Manager)
Amy Shepard, PharmD (Pharmacist)
Carlos Esparza, MSW (Social Worker)
Lynette Menchaca, RN (RN Care Navigator for Palliative Care)
Guadalupe Fernandez, LCSW (Palliative Care Social Worker)
Crystal Hurtado (Pharmacy Tech)
Tiffany Lu, Registered Dietitian (Nutrition)
Cindy Sanchez, CNA (Patient Advocate/Scheduler)
Palliative Care
Serving SVMC’s Roger S. Good Cancer Treatment Center patients, outpatient
palliative care is an approach that addresses the patient as a whole and
aids in enhancing comfort and quality of life after they leave the facility.
The goal is prevent or treat, as early as possible, the symptoms and side
effects of the disease and its treatment, in addition to any related psychological,
social, and spiritual issues. When a SVMC patient is facing cancer head
on, it is imperative to get answers, relief and support. Palliative Care
offers compassionate outpatient care from an interdisciplinary team, while
helping SVMC Cancer Treatment Center patients and their families navigate
the healthcare system. Palliative Care Services include:
Discharge planning
Social services
Case management
When to Get Palliative Care
Outpatient Palliative Care is most beneficial when introduced early on.
When cancer patients are ready to go home, the Palliative Care team provides
services beyond the care given at the Cancer Treatment Center.
PACT Program - Post Acute Care Transitions
The Post Acute Care Transitions (PACT) Program is a fully integrated set
of outpatient services specifically for Congestive Heart Failure, Chronic
Obstructive Pulmonary Disease, and Pneumonia patients. This 30-day program
includes social services with one of SVMC’s excellent Social Workers,
complex medication management with a Pharmacist and Pharmacy Tech; chronic
illness education and case management, as well as nutritional advice.
This program also assists with coordination of Academic Health Clinic
appointments for those that may not have a Primary Care Provider or may
need help in expediting the appointment process.
In addition, the SVMC Bridge Services team helps in navigating California
Advancing and Innovating (CALAim) referrals. These referrals help Managed
Medi-Cal patients in accessing new services provided by local extended
care management providers that help address homelessness, food insecurity
and social determinants of health that impact a patient’s ability
to be healthy at home.
Breaking Down the 30-day Program in Five Steps
From start to finish, the SVMC Bridge Services team takes on a five-step
process. This approach helps in meeting outpatient healthcare needs for
specific patients who often find themselves in a healthcare facility more
than necessary. The goal is to help these patients heal and live a healthier
life without ongoing in-patient care.
Initial Survey: A survey is given to assess engagement ability, social determinants of
health, digital readiness and ability to participate.
The 48-Hour Mark: A post-discharge medication reconciliation and transmission of hospitalization
discharge summary is sent to the Primary Care Provider within two days
of being discharged.
The 7-Day Mark: A telephone assessment of social, medical, dietary and medication needs
takes place and a care plan is then created to address those needs.
15-Day Follow-Up: A team member checks in with the patient to answer any questions that
may have not been addressed by their Primary Care Provider and to address
any issues not resolved.
28-Day Assessment: A few days prior to the end of the program a discharge readiness assessment
is made. Patients who need more assistance will be referred to appropriate
resources as needed.
Throughout the 30 day process, patients receive phone calls and text messages
to ensure social and emotional support, and to coach education that may
have been provided. These informal touch points help the patient feel
connected to the healthcare system with the goal being that patient feels
they have someone to reach out to rather than presenting at the Emergency
Room for non-urgent issues.
