Peyton LaBauve, a senior biology student at
Angelo State University (ASU). ey spend
a couple hours openly discussing how Delrio
is feeling, what he has accomplished that
week and areas where he can improve. La-
Bauve talks to him about his medications
and pain management, and he also accom-
panies Delrio to his doctor appointments.
“I’m the type that doesn’t let anyone into
my personal life,” Delrio says. “I wouldn’t
dare tell anyone if something is wrong except
for my doctor and my immediate family,
but Peyton helps me bring it out. It helps
me when he is at the appointment with me.
We talk before we go into my appointment
and go over what I need to talk about with
Dr. Burgess—things I want to remember to
ask him, concerns I have. It makes it much
easier for me; I’m telling the doctor more
instead of holding back.”
AN INNOVATIVE PROGRAM
e Shannon
Care Coordination program, a partnership
between Shannon and ASU and the rst
program of its kind in Texas, helps patients
like Delrio by pairing him with a student
health coach. It is modeled a er a concept
introduced by Barry Bittman, MD, chief
innovation officer at Meadville Medical
Center in Pennsylvania, and is designed to
bene t the patients, students, community
and hospital.
Irv Zeitler, DO, vice president of medical
a airs at Shannon and course director for
the program, and Bryan Horner, Shannon
Medical Center CEO and president, caught
wind of Dr. Bittman’s successful, innovative
program and approached ASU about part-
nering to begin a program locally.
“ASUwas looking for an outreach program
and Shannon has always been great to let our
students shadow and give back to the com-
munity,” says Russell Wilke, PhD, professor
and department of biology chair at ASU. “ e
program was a perfect t because it aligned
our mission with Shannon’s—to provide
quality health care to our community.”
Before they can become health coaches,
the students must complete the “Community
Healthcare from eory to Practice” seminar
course at ASU. Students are eligible to apply
to the program during their sophomore year.
ey must be pre-med majors and meet a
list of predetermined criteria.
e program involves pre-med students
in the business side of health care while
also giving them experience with patients.
From the beginning, the patient’s physi-
cian agrees that the patient would bene t
from participation in the program, and the
physician continues to make all the clinical
decisions regarding the patient. Students
bolster their medical school applications
while patients gain trained health coaches,
who help manage their care outside the walls
of the hospital or clinic.
roughout the semester, students listen
to presentations from the course directors as
well as Shannon nursing professionals, physi-
cians, dietitians, case managers and health
care attorneys. ey are presented case stud-
ies, and open, thought-provoking discussion
ensues to further prepare them for e ectively
serving as health coaches in the community.
Upon completion of the seminar, students
begin the internship phase where they visit
patients in the home, under the supervision
of a multidisciplinary committee.
“ e goal of this program is to help be
more accountable for population health,”
Dr. Zeitler says. “We want to keep patients
from being readmitted to the hospital for an
existing issue by taking another step to help
them manage their health. at requires us
to step outside of the clinic or hospital set-
ting and into their homes. e research has
shown going to patients in their homes helps
us grasp a better understanding of their so-
cial and health issues. We are changing the
delivery of care while better managing health
care costs for all parties involved.”
Another component of the program that
helps with patient success is that patients are
never discharged. eir visits may decrease
to once a month, or whenever the patient
feels like he or she needs a visit, but the re-
lationship is not stopped unless the patient
requests so.
“If for some reason they are readmitted
to the hospital, we will pick back up with
weekly meetings,” Morales says. “It’s simi-
lar to the relationship they keep with their
doctors. It’s just a little extra help.”
And, a er the rst semester, it’s safe to
say the program is working.
PERSONAL I ZED ASS I STANCE
Lillian
Brown was also approached by Morales
while recovering from open-heart surgery
in the hospital.
During the rst few months of her recov-
ery, Brown’s daughter stayed with her. A er
she returned home, Brown resumed living
by herself while continuing on the path to
recovery, but she was on her own when it
came to remembering to take her medica-
tions or what time her appointments were.
“Lillian is no stranger to cardiac events,”
Morales says. “Her rst heart surgery was in
. erefore, she has medical knowledge
of her condition, but we partnered her with
health coach and ASU senior Michael Kyrouac
to help her better manage medications and
keep a record of the progress of her health.”
A special medication box, supplied
through the program, reminds Brown to
take her daily meds. e box blinks as a
rst reminder and beeps minutes a er
if it has not been opened. If Brown still has
not taken her medication a er that time, an
alert is sent to Morales. Brown says the box,
and Kyrouac, have helped her a lot.
“We sit down, ll my medication box and
make sure my meds are correct,” Brown says.
“We ll out my daily record for weight and
blood pressure, go over all the numbers,
and make sure everything is looking good.
Michael taught me how to log information
in my phone and make a memo. It reminds
SHANNON CARE
COORDINATION
Health coach and ASU student
Peyton LaBauve greets program par-
ticipant Frank Delrio at his home.
Frank Delrio has a lot to live for. e -year-old has two daughters, two grandsons and other loved ones
who care about him. But earlier this year, he lost his only son and found himself in the hospital with health
complications.
at’s where he was approached by Shannon Care Coordination nurse coordinator Sandra
Morales, RN, MSN, CCM, with a unique opportunity to be part of a new program at Shannon. “When
Sandra approached me in the hospital, I had already made up my mind I didn’t want to participate,” Delrio
says. “Looking back now, I’m so glad I did.” Each week, Delrio gets a home visit from his health coach,
“We are
changing the
delivery of
care while
better
managing
health care
costs for all
parties
involved.”
—Irv Zeitler, DO
4
F A L L 2 0 1 4
H E A L T H
B E A T
