After undergoing gastric bypass surgery in August 2008 at Saint Joseph East in Lexington, Ky., Nelda Marshall was urged to attend monthly meetings with a hospital dietician to help her continue to lose weight and eat healthfully. She kept only one appointment.
Lexington is a four-hour round-trip from Marshall's home in rural Jackson, Ky., where she runs a furniture business with her husband. The trek to Lexington meant time away from the store and from her elderly parents who are in ill health and require daily monitoring and help with basic tasks.
"It was just so difficult for me to go to those meetings," said Marshall. But, over time, her weight began to creep up. "I worked too hard to see the weight come back on. I knew I needed help staying on track, but traveling to Lexington every month with all of my commitments was not possible."
Then last spring Marshall read about a Saint Joseph Health System dietician coming to Jackson to help current and former patients. "I called immediately and made an appointment," said Marshall. "Driving five minutes to a local clinic as opposed to two hours — now that was something I could do."
Since June, Marshall has been meeting monthly with Barbara Baumgardner, a registered dietician who is part of Saint Joseph Health System's Appalachian Outreach Program. For 25 years, the program has provided follow-up visits, support and assistance — all free of charge — for Saint Joseph patients from underserved areas in rural Eastern Kentucky. The health system, which is a member of Englewood, Colo.-based Catholic Health Initiatives, operates seven hospitals across Kentucky with a total of 1,012 beds, 5,000 employees and 1,300 physicians.
"First and foremost, the Appalachian Outreach Program really embodies the commitment of Saint Joseph Health System to being in service to those most in need," said Dr. Dan Varga, the health system's chief medical officer. "The Appalachian counties of Kentucky are some of the most underserved counties in America. They have the worst health outcomes and the highest burden of disease in the country. The outreach program really has been designed to try to get those services not typically available to communities literally to their doorstep."
A long reach
Every week, outreach social worker Jeanie Lawson downloads a list of patients from 11 counties recently discharged from Saint Joseph Hospital and Saint Joseph East. "I call everyone on my list to see how they are doing," Lawson explained. "From those calls, I glean who will benefit from a home visit.
"I may have patients with a new cancer diagnosis, one who has fallen and broken a hip, one coping with multiple issues like dialysis and chemo, one who has passed away and I need to follow up with a family member. There is any number of variables." She's on the phone frequently with family caregivers.
Lawson then gets permission and directions to make a home visit, clustering patients in the same geographic area so she can see several in a day. She drives between 1,200 and 1,600 miles every month.
"The biggest benefit is the concern this program shows for the health of the rural patient. Plus, it is totally free of charge," said Lawson. "I had one patient whose 82-year-old husband passed away last week tell me, 'You are the first person who said I am so sorry you lost your husband.' She so appreciated that personal touch.
"I also hear from people all the time, 'I am so proud you came to see me.' They are impressed by the outreach and so grateful to be looked after."
Nutrition education
Dietician Baumgardner mostly sees patients in hour-long sessions at local clinics in 13 rural counties. Many are dealing with cardiovascular ailments and hypertension, or suffer from health concerns related to obesity and diabetes.
"I also see a lot of people who are not well-informed and have no access to nutritional education," she said. "I got to talking to one woman recently (who was) concerned because her young daughter is very overweight. I asked what she was feeding the child. She told me she'd give her a box of macaroni and cheese, thinking it was one serving size. She had no idea about portion control."
Much of Baumgardner's time is spent educating patients about the importance of exercise and eating healthfully, developing personalized meal plans and helping them to overcome obstacles.
"Some have concerns that eating healthy is expensive," she said. "I try to show them how they can get good, clean food, like high-fiber beans and seasonal fruits and vegetables, cheaply."
Baumgardner says obesity has become even more widespread in Appalachia than it was when she first began her outreach practice nine years ago. "Patients also tend to be sicker," she said, "because they don't have the ability to pay and wait longer to come for help. When they find out our service is free and we come to them to deliver care, they are just so thankful."
Count Nelda Marshall among the grateful patients. After losing 80 pounds following her gastric bypass surgery, then gaining 16 in the few years that followed, she has taken off five since June when she began seeing Baumgardner.
"Barb has gotten me back on track and keeps me motivated. She is my stabilizer," said Marshall. "When we meet, we discuss everything I am eating and critique how I am doing and see what might help. She found me a low-carb yogurt that I can use for a snack. I am crazy for yogurt, but the kind I had been eating had too many carbs. She has made all the difference in helping me be healthy."
Poverty's porch
The Appalachian Outreach Program was begun in 1986 by Sr. Betty Shelton, SCN, and her congregation, the Sisters of Charity of Nazareth. As Sr. Shelton once explained: "I used to dream about going to India or Belize, but it never seemed to be right for me. Then I started thinking of all the people right here in Kentucky who have similar needs ..."
When she started the outreach, Sr. Shelton traveled the back roads in nine counties to help patients who had been discharged from Saint Joseph Hospital. In 1991, Sr. Joan Wilson, SCN, joined her, and the program grew to 15 counties. Two years later, a nutritional counseling component was added with a third staff person who delivered help to patients through home visits, phone calls and mailings.
"The program is and has always been very grassroots," said F. Rose Rexroat, community services and virtual care manager at Saint Joseph Hospital. The outreach program falls under her purview.
"The sisters were instrumental in figuring out and helping these patients get what they needed and putting them in touch with community resources," she added.
Rexroat said Sr. Wilson, the last sister working full-time in the program, retired recently, and she will be succeeded by a full-time chaplain. That person will join Baumgardner, who came on board in 2002, and Lawson, who was hired a year later. In addition, a three-year project grant from CHI's Mission and Ministry Fund will allow two registered nurses to be added to the team in the coming months.
"This will expand the program and really focus on not only making sure patients have the resources they need to stay home and be independent, but also allow them to increase their self-management skills, avoid hospitalization and coach them to avoid high-cost emergency visits," said Rexroat, noting that the program now serves patients in 27 rural Kentucky counties.
Added Varga: "One of the things we are trying to emphasize is getting primary care services close to where people are. If we don't, there is a high likelihood they'll end up in a much more expensive venue of care, much sicker and less likely for a good outcome. For us, it's more of a preventive strategy. We're really looking for a better answer for the patient."
Services provided by Saint Joseph Health System's Appalachian Outreach Program
Pastoral services: Compassionate listening, grief counseling, spiritual counseling, family support and prayer
Social services: Referral assistance; interface with county agencies, social service agencies, physicians' offices, and Saint Joseph Health System facilities and departments
Palliative care: Support palliative care team at Saint Joseph Berea
Nutrition services: Nutritional therapy for diet-related disease and conditions including, but not limited to, diabetes, cardiac disease, hypertension, weight management, digestive diseases and anemia