Sharon Rateau noticed that her mother, Mary Ware, wasn’t doing well.
“She was moving slowly and having problems focusing,” said Sharon. “We scheduled a doctor’s appointment, but had to keep postponing it. When we finally met with Dr. Laura Howard from Palmyra Medical Associates, she urged us to see a cardiologist the next day. He said my mother’s heart was beating so fast that he couldn’t get a clear picture.”
The cardiologist directed Mary to Sentara Martha Jefferson Hospital.
“When we got to the ER, they told us my mother was experiencing Afib, atrial fibrillation. They admitted her,” said Sharon.
Atrial fibrillation is the most common cardiac arrhythmia, which means irregular heart beat. Patients with Afib, as it's known, experience a faster than normal heart rate.
Mary, a former nurse, was amazed at the attention she received and particularly enjoyed meeting a husband-and-wife team: David Zerrlaut, a heart specialist patient educator, and Myrinda Zerrlaut, a floor nurse.
She didn’t even mind that David’s job is to make sure he never sees patients again.
“I talk with patients about their heart conditions. We don’t want them to have to be readmitted. Anytime you’re in the hospital, it’s getting harder and harder for you to fight off the progression of the disease. I spend about 45 minutes covering every aspect of a patient’s condition –what it is; what symptoms look like; how to avoid coming back to the hospital by making lifestyle changes. I tell them to watch for weight gain, shortness of breath, fatigue and swelling of the ankles.”
Nurse Sharon “J-J” Peacock provided more guidance once Mary was discharged:
“I work at Palmyra Medical Associates. I’ll call those patients who were in the hospital and go over their medications,” said J-J. “I check that an appointment has been set with us and with any recommended specialists and if not, schedule an appointment. I make sure the specialists get any notes from us and the hospital. I check on other details. Is home care scheduled for a visit or is anyone – any family – with the patient? I consider all I do to be ‘transformation of care,’ a collaborative, patient-focused effort at every care setting and between the different settings.”
Reviewing and improving patient care
Camilla Washington, clinical educator-transformation of care coordinator with Sentara Martha Jefferson Medical Enterprises, keeps a watchful eye every step of the way for patients like Mary:
“I review how well staffers carry out procedures that can keep patients healthy. I look at reports to see how many patients where discharged from Sentara Martha Jefferson Hospital and if they went home,” Camilla explained. “I check to see whether or not they received needed help from Home Health, and I look at whether follow-up appointments got scheduled.”
Our goal is to make the transition from hospital to home seamless. Patients are touched that nurses call to see that they’re OK after a hospital stay. They’re surprised that their doctors and nurses know they were in the hospital.
Camilla works on educational materials also.
“We want them to be understandable, consistent and timely. Patients are part of the care team now. They need to be informed,” she said. “Everything we’re doing is to keep patients from being readmitted to hospitals.”
Her efforts – and everyone’s at Sentara – worked: Mary reports that she is doing well, and she thanks the staff at Palmyra Medical Associates, Sentara Martha Jefferson Hospital and Sentara Martha Jefferson Medical Enterprises, all part of Sentara Healthcare.