Catholic Charities West Virginia: Reducing Hospital Readmission Rates in Wheeling

When Sister Jen Berridge visits patients in their rooms at Wheeling Hospital, more often than not she comes bearing gifts: a box of groceries, paper goods, and hygiene products from the on-site Catholic Charities food pantry for the patient to take home. 

As the Hospital Transition Program case manager for Catholic Charities West Virginia (CC WVa.), Sister Jen supports vulnerable West Virginians to ensure a safe and smooth transition from a hospital stay to their home or other stable housing. 

Sometimes, that means providing the essentials in that grocery box, so patients can be comfortable as soon as they arrive home. Other times, it’s connecting them with the Catholic Charities shelter or other resources that provide a safe place to stay. And in many cases, it means continuing to visit them wherever they end up, to make sure they have the food, medicine, and transportation they need to stay healthy and make it to future checkups. 

“It’s very important to earn the patient’s trust, because sometimes they’ve been burned by different social service agencies and folks in their lives,” says Sister Jen. “The patients are wondering who I am and what I’m doing. So, it’s just building relationships.” 

CC WVa. launched the Hospital Transition Program in March 2021, the only program of its kind in the state, with funding from a grant they received for winning the medium agency category of the Catholic Charities USA Innovation Challenge for their submission of this program. Their goal is to significantly reduce hospital readmissions at Wheeling Hospital and help improve the quality of life for discharged patients in vulnerable populations. 

When they decided to create this new program, two local hospitals had recently closed, which made it even more important to reduce preventable readmissions at the remaining Wheeling Hospital. And the Catholic Charities staff had noticed a pattern of negative effects post-hospitalization for people in some of their existing programs. 

“We started seeing clients who were being released from the hospital and then showing up on the door of our homeless shelter,” says Beth Zarate, the President and Chief Executive Officer of CC WVa. “And we knew through our home care program, where we serve vulnerable and elderly folks, that people [who needed support] were getting missed. So, we went to the Catholic Charities network, because we have gotten tremendous support from CCUSA.”  

CC WVa. staff consulted with their counterparts in Chicago, who run a similar program, for advice, and then tailored those recommendations for their more rural location. The population of the entire state of West Virginia is smaller than the Chicago metro area, and many people live in less accessible areas. In the Chicago hospital transition program, they schedule next-day home visits from Catholic Charities as part of hospital discharge. Next-day visits aren’t feasible for a one-person team with patients as widespread as they are in rural West Virginia, so the West Virginia staff took a different approach: meeting with patients during their hospital stay. If hospital staff or social workers have concerns about patients going home to a stable environment, they call in Sister Jen, whose office is located in Wheeling Hospital. 

“When Sister Jen is establishing a rapport with someone, they’re not afraid to be honest with her,” says Deacon Paul Lim, the Vice President of Mission Integration at Wheeling Hospital. “What I’ve found is, when patients present to [the medical team], they often will paint a picture that puts their best foot forward, and that may not be actually how it is. With Sister Jen, you don’t have to worry about that. She gets a good assessment of what they need.” 

Once a patient is discharged, Sister Jen will visit them within 72 hours. She’ll bring more groceries, offer a ride to follow up appointments, or make sure the patient has what they need to be comfortable. For Wheeling resident Laurie Quinn, who was admitted to the hospital after a severe fall at home, Sister Jen obtained a more comfortable chair for her to sit in at home during recovery. 

“Sister Jen has been a very big help,” says Quinn. “She has helped me out with food orders, with blankets and pillows, and a chair for me to get in and out of more easily, because when I got hurt it was hard to sit down.” 

There are some inherent challenges to operating a program like this in West Virginia, notes Sara Lindsay, the chief program officer for CC WVa. 

“West Virginians fall to the bottom of all the charts for health, but there is a spirit there. There is a culture of resiliency and helping one another,” says Lindsay. “They’re very prideful and they’re very resourceful. Sister Jen meets people who are very cautious about letting in a stranger, and that’s why it’s important to have the right people as staff, so Sister Jen is able to help them trust her over time.” 

In some cases, it takes a few visits for people to feel comfortable letting Sister Jen inside their home, which she respects and understands. She calls those her “porch conversations.” 

“I talk about whatever they feel comfortable talking about,” Sister Jen says. “I have one patient, I said, ‘Oh, what are all these toys out on your front porch?’ And she said, ‘My granddaughter comes a couple days a week,’ and we just talk about that. And then she opens the door a little bit.” 

One of Sister Jen’s patients was hesitant to accept help from the local housing authority, but without it, he was planning to stay in his car when he was released from the hospital. Sister Jen patiently convinced him to accept the help, and when he was released while still needing supplemental oxygen, he had a safe place to stay. 

“One of the most beautiful pieces of this project is that fluid integration of our services and the hospital system. Those people who are discharged and have transient housing, like their car, for example, they would have to make their way to our shelter in a worried state,” says Lindsay. “Now, they’re meeting Sister Jen in the hospital before they are even discharged and they’re leaving the hospital with that helper already in their pocket. And that’s huge.” 

The program recently hired a second case manager to assist Sister Jen, and they are working with the Lab for Economic Opportunity at the University of Notre Dame to collect statistics on the program’s impact. Down the road, they want to expand to other hospitals, in addition to Wheeling Hospital, and establish a network of volunteers to help case managers with the home visits. 

“I’m definitely proud to say that of all the people that we’ve referred to Catholic Charities, none of them have been readmitted to the hospital,” says Deacon Paul. “And that’s the name of the game. For a hospital, if a patient has to come back, we see that as a failure. That means we didn’t do something on our part. In West Virginia, the problems are not always medical; a lot of them are based on the social determinants of health [like economic stability and neighborhood environment]. And so, if we can refer them to the experts, like Catholic Charities, for the social things, while we handle the medical things, then the patients are guaranteed to do well.” 

Deacon Paul pointed out that they were anecdotally referring patients to Catholic Charities services, like the Neighborhood Center and food assistance programs, before the creation of the Hospital Transition Program. “Once we know about something awesome, we’re going to refer people to it,” he says. Now, with the official partnership, “Catholic Charities has time to figure out the patient’s needs.” 

That kind of partnership and collaboration is essential for other Catholic Charities locations looking to create this type of program, says Mark Phillips, the Northern Regional Director at CC WVa. He oversees programming in the region of the state where Wheeling Hospital is located. 

“We’re really fortunate to have Wheeling Hospital; they’ve been great partners. You need a hospital partner that is really committed to community health,” Phillips says. “On the financial side, if we can decrease the number of Medicare and Medicaid recipients who are using the emergency room as primary care, then it’s better for everybody. And if we’re there to help with that transition to home, it helps to improve long-term community health in the area. West Virginia is at or near the bottom of every major health indicator. When you have a hospital partner that recognizes that and wants to make a real difference in the community, it’s an easy program to sell.”