Bridging the Gap Between Hospital and Home

From the Summer 2014 edition of Vanderbilt Medicine Magazine

One year ago, Kris Stevenson was dying on the trauma unit at Vanderbilt University Hospital. He had been hit by a car while crossing the street in Nashville, resulting in severe brain, pelvic and abdominal injuries. Today he is walking and talking thanks to a team of people who helped with his incredible recovery.

Case manager Tanya Parrish, R.N., and social worker Josh Owens, LMSW, are part of Vanderbilt’s Transitions Program, which helps move patients from the hospital to home or another care setting. In Stevenson’s case, they worked with National HealthCare Corporation (NHC) in Milan, Tennessee, to find an appropriate skilled nursing facility for him.

“We weren’t sure he would improve, and thought he would probably be bed-bound and wheelchair-bound the rest of his life. I did not anticipate by any means that he would be up walking and talking,” Parrish said.

The Transitions Program began in fall 2012 with the novel approach to pay for post-acute services for some uninsured patients on an as-needed, case-by-case basis. Often these uninsured patients remain at Vanderbilt when they could better recover at a skilled nursing facility or through home health.

Stevenson arrived at NHC-Milan on July 15, 2013, and the rehab staff immediately began working with him.

“When I evaluated him, he was verbal but didn’t follow commands. He would not move his legs and if you tried to move them, he would scream,” recalled physical therapist Tonya Pigg. “But that first week I could see his quad muscle kicking in, and every week after he was showing more improvement.”

Stevenson took his first steps on Aug. 23, 2013, and never looked back.

Parrish is still following Stevenson’s case and is working to get him an appointment in the Vanderbilt surgical clinic to evaluate reversing his colostomy. The NHC-Milan staff is working on the next step for Stevenson, possibly a group home setting with other patients his age.

“A year ago we didn’t think he would be where he is today, so I wouldn’t dare put a limit on where he could go,” Owens said.

–Leslie Hill