Continuum of care

from the Winter 2018 issue of Madison

By Jim Heffernan ('96)

Soon after joining Sentara RMH Medical Center in August 2013, Patra Reed (’93, ’16D) helped initiate a Continuum Case Management program in which chronically ill patients were assigned a registered nurse upon their release from the hospital. But one year into the program, the caseloads for these RNs were increasing and they were performing duties that did not require nursing training.

A member of the inaugural class of JMU’s Doctor of Nursing Practice program, Reed began surveying the literature for best practices to better manage the needs of patients served by the continuum case management program. She discovered the role of the community health worker, who serves as a liaison for the patient’s health, welfare and community needs, “whether it’s filling out paperwork for financial assistance or Medicaid, or educating them on self-managing their condition.”

For her DNP project, Reed was awarded a $200,000 grant from the RMH Foundation to pilot the addition of three community health workers to assist patients in the central Shenandoah Valley with chronic heart conditions. The study yielded “tremendous” outcomes, she says. “We were able to reduce [hospital] readmissions, decrease emergency room visits, increase patient quality of life and substantially decrease health care costs.”

In today’s health care climate, that’s a winning formula.

“The current complexities in health care and the demand for safer care are more important than ever,” says Linda Hulton, professor of nursing and director of the DNP program at JMU. “Health insurance companies and the federal government are demanding increased accountability and decreased cost.”

By some estimates, nearly half of the U.S. population—133 million Americans—has at least one chronic disease, driving up health care costs. These conditions account for 7 in 10 deaths annually in the U.S.

As the only hospital in the Sentara system that is currently using community health workers, RMH’s patient outcomes are being closely monitored to determine if they can be replicated.

As Sentara’s Blue Ridge regional director of integrated care management, Reed is responsible for leading, directing and deploying innovative initiatives to support these patients and their families across the continuum of care. “These patients have lots of needs—medical, psychosocial, financial—that cannot always be met while they’re in the hospital,” she says.

As the only hospital in the Sentara system that is currently using community health workers, RMH’s patient outcomes are being closely monitored to determine if they can be replicated. Reed’s original study involving 41 heart failure patients has since been expanded to other chronic care populations.

Reed also serves as director of Sentara RMH’s Community Health division, which is focused on health education and prevention. “We have programs for at-risk mothers during pregnancy, children and the elderly, as well as school programs on safety and health,” she says.

Reed participated in the Doctor of Nursing Practice program's first Health Policy Institute in Washington, D.C., where she helped draft policy briefs for U.S. Sen. Tim Kaine and his staff on the Zika virus, opioid addiction and hearing aids for children.

Reed’s 25-year career in nursing began in the intensive care unit at Kings Daughters Hospital—now Augusta Health—in her hometown of Staunton, Virginia. The undergraduate education she received at JMU prepared her for numerous leadership opportunities over the years. Reed had always wanted to pursue a doctoral degree, and when she learned that JMU was offering the DNP, which is focused on putting nursing research into practice, she jumped at the opportunity. “It was really exciting to be part of that first class,” she says.

Reed was one of five DNP students to participate in the program’s first Health Policy Institute, a weeklong immersive experience in Washington, D.C. She and a colleague were assigned to Sen. Tim Kaine’s office, where they drafted policy briefs for the lawmaker and his staff on the Zika virus, opioid addiction and hearing aids for children.

Initially reluctant to embrace health advocacy, Reed soon adapted to the role. “I gained a new appreciation for policy and advocacy,” she says, “and what a difference we, as nurses, can make.” She has since joined a group looking to establish certification standards for community health workers in Virginia and is active with the American Nurses Association in supporting health care reform.

In April, Reed received The Graduate School’s Civic Engagement Award, which recognizes a student’s academic, co-curricular or service activities that exemplify JMU’s vision of civic engagement.

“As a seasoned nurse, Dr. Reed is passionate about care of vulnerable populations in her community,” Hulton writes in her nomination letter. “She is a wise counselor, a standard bearer of integrity and civility, and is viewed by both faculty and colleagues as a true scholar. Throughout her career, she has nurtured the altruism of many staff, professional nurses and JMU students.”

Asked what she finds most rewarding about her job, Reed says her staff is driving change and improving health in the community. “I hear from our case management team, ‘I saved this patient from having to go to the emergency room today.’ That’s a wonderful feeling.”