Bridge Services

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.

Questions? Contact Devon Barlow-Merritt (DMerritt@sierra-view.com, 559-788-6081)