Unique collaboration brings together smooth transition for patients


By Sue Cody


Jeanette SchacherAn amazing collaboration has developed between Providence Seaside Hospital and Astoria’s Columbia Memorial Hospital (CMH) to better care for residents on the North Coast.


Lower Columbia Hospice, a department of CMH, has proven successful. But when CMH realized its home health program was not financially feasible, it looked at what consequences would result if it stopped the service. “If we pull out, what is left?” Jeanette Schacher, hospice manager, said. That’s when Providence Seaside came into focus.


Providence has a robust home health program, providing therapy and nursing services to homebound patients, while CMH’s hospice meets the need of end-of-life care.


So the two health care organizations agreed to complement each other instead of compete.


“In a small community like this, collaboration really benefits all the patients,” said Mary French-Peterson, home health manager for Providence Seaside.


Leading up to the collaboration, a committee met monthly to assess patient needs and how they were being met. One outcome is that home health can refer clients to hospice and vice versa.


“By communicating with each other instead of competing, we help the patient’s transition from home health to hospice. It benefits the patients to receive care at the proper service level,” said French-Peterson.


“This is a unique experience and the first opportunity to really, truly offer the best services to our community,” Schacher said.


“It really worked out great,” French-Peterson said. “We even had a mixer with all the nurses. We talk on the phone all the time, so it was nice to meet each other in person.”


Home health


Home health offers an extensive array of medical and social services to help people remain in their home during illness or recovery. Palliative care eases physical, mental and emotional suffering. It is an extra layer of care to control symptoms at home for diseases such as COPD, congestive heart failure or diabetes.


“We ask what is most important to the patient and communicate the tough conversations, such as advance directives and POLST (physician orders for life-sustaining treatment) forms,” French-Peterson said.


To qualify for home health, people must be homebound and in need of a skilled nurse for physical, speech or occupational therapy.


A home safety evaluation takes into account risks such as throw rugs and pets, to make sure the environment is safe.


Physical therapy focuses on home exercises and regaining strength. Occupational therapy helps people get back to their daily activities, like bathing, dressing and preparing meals. Speech therapy covers swallowing and speech difficulties.


Social workers direct people to community resources. If a patient can no longer drive, they find transportation. They provide comfort and support families in times of crisis. A home health aide assists patients in bathing and personal care. Service is delivered between 8 a.m. to 4:30 p.m.




Hospice care serves the needs of patients who are no longer seeking curative treatment, and offers end-of life-care. A hospice facility became too expensive to maintain, Schacher said. Now 80 percent of hospice patients are served in their homes, and 20 percent are in assisted living centers or adult foster homes. Service is available around the clock.


Medicare pays for equipment, medical director service, aides, bathing support and light housekeeping. The program offers therapy, spiritual support, respite for caregivers, and massage therapy for the patient and caregivers. It follows up with bereavement support for 13 months after a person dies.


Transition from Home Health to Hospice


When a nurse, physician, patient or family member decides hospice is more appropriate, the situation is evaluated and a patient can transition smoothly from home health to hospice.


Through this collaboration, nurses are able to share information, data and ideas about what is working. The big plus for patients is they can meet caregivers in a joint visit from Providence Seaside and Lower Columbia Hospice to plan their transition.


“Before, it was every man for himself,” Schacher said. “There was less willingness to share information. Now we can share what’s working with each other.”