C O L L A B O R A T I V E C A S E M A N A G E M E N T

Tapping Into a Sense of Community:

New Program Uses ‘Old’ Way to Help Patients Lacking Social Support
By Deborah Z. Morgan, BS, CPRS; and Crystal J Redding, RN, BS

The custom of “neighboring” has altered significantly over the past several decades, and many people bemoan the loss of community and
caring for each other that existed in the past. But two innovative programs that tap into the “old” ways are benefiting inpatients and discharged
patients of Forsyth Medical Center, an 856-bed hospital in Winston-Salem, N.C., that is part of the not-for-profit Novant Health system. These
programs demonstrate that the old “neighbors caring for neighbors” spirit is not extinct. It can be effectively marshaled to assist patients of
any age who lack a built-in social support system, both while they are in the hospital and after they return to their homes, assisted living centers,
or nursing homes.

Times have changed, and neighborhoods have changed.
Families, too, have changed – in part because Americans are much
more mobile than they used to be, and adult children often live
hundreds of miles from elderly parents. For these and other reasons,
many people today lack the “old-fashioned” social support systems
common in the past. This can negatively impact persons who go into
the hospital, receive few or no visitors, and are discharged weaker
and less independent than they were when they entered. It might
even mean they are not able to return to their own homes, but have
to move temporarily or permanently into some type of care facility.
“A lonely patient is an unhappy patient.” This realization by the
Forsyth Medical Center Service Excellence manager led to the
formation four years ago of a Patient Partners program. Volunteer
hospital employees from any department are paired with, or
“adopt,” hospital patients who have little or no social support. This
program was well received and successful, and 2004 saw the
introduction of a second program, Community Partners, which
assists patients after they leave the hospital.
Patient Partners is a program conducted entirely by Forsyth
Medical Center, while Community Partners is a collaboration
between the medical center and an independent hospice in Winston-
Salem. However, Community Partners is not limited to persons who
are terminally ill. Any patient discharged from Forsyth Medical
Center who does not have an adequate social support system is
eligible for Community Partners, if he or she wishes to take advantage
of it. These individuals have more extensive needs than hospitalized
patients, and rather than having just one person to assist, as for
inpatients, a support team is tailored to address these needs.
Case managers play a key role in both programs, but their
workload is not appreciably increased by this role. Via the social
needs assessment, they promptly identify newly admitted hospital
patients who could benefit from Patient Partners and, after
discharge, from Community Partners. With the patient’s permission,
patients are referred to the Patient Relations department. Case
managers appreciate the Patient Partners program because it helps
most patients to be more relaxed and contented, and the
Community Partners program often provides case managers with
alternative discharge possibilities. Not always, but in some cases, a
Community Partners team can enable the patient to return home
rather than having to move into a care facility.
PATIENT PARTNERS
The strategy of the Patient Partners program is to enhance the
patient experience by anticipating and addressing needs of patients
who lack family or friend support. Social support can easily be
provided by volunteer employees without detracting from these
employees’ required duties. The time commitment is a very small
part of the work day. However, both patients and employees gain
from the experience. For many employees who work in departments
without direct patient contact, this provides a chance to feel more
closely connected with the hospital’s primary function, patient care.
Patient partners are encouraged to contact their “adopted”
patients as soon as possible after being assigned by the Patient
Relations department. The employees make short daily visits, once
or twice a day before and after the patient undergoes surgery or
another procedure. They help care for patients’ belongings, assist
them with basic tasks such as making outside phone calls or
contacting appropriate professionals from other departments (for
example, chaplains, food services, or the volunteers’ “Wacky Wagon”
humor cart for a much-needed mood lift), and help the patient on
the day of discharge. In general, the patient partner becomes a
friend and an advocate, helping to make the hospital experience as
pleasant and stress-free as possible.
Patient partners are asked to fill out a report form for each
patient assignment, and return it to Patient Relations. Employees
may send “get-well,” “thinking of you,” or birthday cards after their
patients have been discharged. However, if they wish to take on
any other responsibilities for former patients outside the hospital,
they are asked to consult first with the program leaders. It may be
possible for them to become part of that individual’s “Community
Partners” team.
COMMUNITY PARTNERS
Community Partners is a collaborative project of Forsyth
Medical Center, through the Patient Relations department, and The
Community Partnership for End-of-Life Care, a program of the
Hospice and Palliative Care Center. It is funded by a grant from The
Duke Endowment, Caring Community Division, first awarded in
2004. With this grant, education is provided for persons who wish to
become team leaders for the Community Partners program.
To begin, the medical center and the hospice contracted
with The Support Team Network at the University of Alabama-
Birmingham, to come to Winston-Salem and present a two-day
educational workshop. The Support Team Network is a training and
resource center for the development of volunteer support teams to
help persons with health concerns or other special needs. It was
started at UAB in 1985, during the AIDS crisis.
The workshop presented was known as a Support Team

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 w w w . a c m a w e b . o r g

Initiative. This is described as “a practical way for several interested in railroading, so they got in touch with a railroad interest
organizations to share a common training and to learn from each group and found a member who would visit the man once a week.
others experiences to develop more and healthier teams.” It is Sometimes, estranged relatives can be contacted and encouraged to
designed to empower a community to create and sustain teams in re-enter the picture.
various situations and places. Eighty-eight persons from a variety of A team might assist for a brief period of recovery, for example,
backgrounds attended this workshop, and today they serve as team following surgery. When extended support is needed, the team’s
leaders and contacts in the community at large. involvement may be ongoing, with tasks and team members
Some of them also serve on the 10-member Steering Committee, changing to meet evolving needs. Team members may, if they wish,
which is responsible for coordinating the Community Partners “sign on” for a specific length of time. When this time is over, they
program. This committee includes hospital, hospice and community are replaced with a new team member.
representatives. Discharged patients sign a form permitting Forsyth Medical Center has found a niche, a “new” way of caring
information about their needs to be shared with members of the for people that is really old-fashioned. No new staff members have
support team assembled to help them. A been added, and the cost to the
team leader designated by the Steering hospital is minimal. The main expense
P A T I E N T ’ S R E A C T I O N :
Committee meets with the patient has been printing brochures to let
before he or she is discharged, to find out patients, as well as potential
whether there are any nearby relatives, a
church connection, neighbors who
‘Cathy is my angel’ volunteers, know about the programs.
And judging by the positive feedback
might be willing to visit and/or help with from patients, discharged patients,
“I was in the hospital by myself. My boys and my brother
specific tasks, and so on. hospital employees and volunteers
weren’t able to help me. The day I went in for surgery,
The support team consists of in the community, both Patient
Cathy showed up to take care of my things.”
volunteers in the community who are Partners and Community Partners
organized and trained to provide The speaker is Myron, a former Forsyth Medical Center are extremely successful programs.
support to individuals and families patient who was paired with hospital employee Cathy, While no concrete figures regarding
with limited support or resources, or first in the Patient Partners program and later in cost savings to the hospital are
other special needs. A team may Community Partners. Myron describes his experience available, it is a valuable asset to
include friends and neighbors who are very positively. case management because it
already involved in the patient’s care, “I got out of surgery, and Cathy was waiting for me. provides a tool to help ensure a safe
or it may be made up of members of She visited me every day. When I went into the nursing environment and appropriate support
local religious congregations who home, she said she would visit.” However, Myron admits
system for patients who might
would like to help someone in the otherwise be difficult to place. The
he wasn’t sure whether she really would.
community. Team members simply do program enhances the likelihood of
what they enjoy doing for others, when “But on Sunday, she came walking in. That was a year continued medical compliance and
they are able, in an organized way. ago and she still comes to see me nearly every week… reduced recidivism.
Activities of the support team are She is the only person who has never, ever, broken a
promise to me.”
Deborah Z. Morgan is manager
determined by the needs of the
of Service Excellence in the
patient and the skills, interests, and Myron concludes, “I love my brother and I love my boys Patient Relations department at
availability of team members. Some and I wish they were able to see me more often. Forsyth Medical Center in Winston-
examples include running errands, But I’d rather have Cathy around than anybody else. Salem, N.C. She has been a healthcare
doing yard work or household chores, She’s my angel. It’s made a world of difference to have professional for 33 years, originally
bringing occasional hot meals, or her as my friend.” in respiratory therapy and for the
making friendly visits. Support team
past 18 years in Patient Relations.
members do not, however, provide
Ms. Morgan holds a BS degree in
any medical services such as
Industrial/Organizational Psychology
dispensing medication, changing bandages or cleaning wounds.
from High Point (N.C.) University, and is in the MBA/MHA program
And they do not provide financial assistance or pay bills.
at Pfeiffer University.
Assembling a support team is sometimes a challenge, especially
in the case of patients who may have “burned their bridges” with Crystal J. Redding is director of Case Management at Forsyth
relatives or neighbors. But team leaders are persistent and will not Medical Center and Medical Park Hospital of Winston-Salem, N.C.,
give up, trying a multitude of avenues until they have found people divisions of Novant Health, Inc. With an ADN from West Virginia
willing to help with what needs to be done. They consult Case Institute of Technology and a BS in health management from
Management to learn what services the individual qualifies for, and Gardner-Webb University, she is pursuing an MHA at Pfeiffer
they also have a list of all the city’s special interest groups and clubs. University. Before going into case management, she was a staff nurse
In one instance, they learned that a man without social support was with 25 years of varied experience.