When Melissa Dausen, BSN, RN, CCM, spearheaded the opening of the Salinas Valley Memorial Health System Transitional Care Program in 2015, she and her colleagues could not have foreseen the COVID-19 pandemic. But the program wound up being the ideal leaping off point for creation of the SVMHS COVID Clinic, which has prevented numerous readmissions and, likely, saved many lives.
Meeting a Dire Need
Early in the pandemic, SVMHS CMO Allen Radner, MD, asked Dausen to create the COVID Clinic from an empty office across the street from the hospital. Dausen pulled together essential clinical equipment and PPE, while engaging physician volunteers from the SVMHS hospitalist service. The clinic began seeing patients in April 2020.
“All of these patients are discharging [including from the ED] with a positive COVID test and require 14 days of isolation,” Dausen says. The Transitional Care Program calls the patients twice during the first week and weekly for 30 days. The clinic also provides additional care coordination for sicker patients with comorbid conditions or who might need oxygen or medication adjustments.
Initially, clinicians saw one to four patients a day. Without dedicated RN staff, Dausen herself cleared three hours a day to see patients along-side the hospitalist. As the pandemic wore on, the caseload increased, necessitating a move to a larger space, with four exam rooms, where dedicated staff could provide in-person follow-up appointments two full days a week, seeing as many as 30 patients per day.
“We’ve even had quite a few patients come in to be checked and realize they’re in A-fib or with pulmonary edema or embolisms,” Dausen says. “I truly believe if some of our patients had not come to their appointments – they would not have survived.”
Saving Lives, Preventing Readmissions
“I truly believe if some of our patients had not come to their appointments – they would not have survived.”
Melissa Dausen, BSN, RN, CCM
Director, Continuum of Care
Dausen feels certain that Brooke Robinson, RN, CCM, Transitional Care Coordinator, may well have saved one patient’s life. During this patient’s hospital admission, it became clear that he was resistant to using the needed oxygen at home. Concerned, Robinson spoke to him several times in the first few days after discharge and arranged for the oxygen company to show him how to use the oxygen. Eventually, she sent a transport team to bring the patient in for a follow-up appointment.
“When he got here, he was gray and ashen, with his oxygen saturation at 70%,” Dausen says. “He was admitted immediately, got better, and eventually was discharged home.” Robinson received a DAISY Award® for her passion and persistence.
As of January 5, 2021, the COVID Clinic had covered more than 1,000 patient visits since opening, keeping the readmission rate for its highly vulnerable patients to less than 6.5%. Dausen says those results speak to the dedication of the nurses, the hospitalists that stepped up and the unwavering support from SVMHS hospital administration.
