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SHHE Project

Support from Hospital to Home for Elders (SHHE) Project: A 700 person randomized controlled study led by co-investigators Jeff Critchfield, MD and Sue Currin, RN, MS.

The Support from Hospital to Home for Elders (SHHE) Study is a clinical trial that is assessing the impact of discharge interventions in SFGH’s ethnically and culturally diverse safety net setting. The Study, generously funded by the Gordon and Betty Moore Foundation, is a hybrid of principles from Project RED, the Care Transitions Intervention, and patient-centered methodologies. It is the first transitions intervention randomized control trial to target English, Spanish, and Chinese-speaking patients over the age of 55 with language and culturally concordant one-on-one nursing interventions. Patients admitted to SFGH are assigned to work with one of a diverse team of nurses that reflect the cultural and language diversity of the target population. This “transitionalist” nurse then shepherds the patient and their family members through the process of preparing for the transition home and into the care of their primary care provider/medical home.

In the role of transitionalist, the nurses have three primary functions. The first is as patient and care-giver coach, engaging and activating patients and care-givers through motivational interviewing techniques and goal setting to help ready them for the self-care and care navigation challenges after discharge. The second function is as educator, using a combination of teach-back and traditional bedside teaching techniques to help patients understand their diagnoses, medications, and post-discharge care plan. The third function is to promote coordination through medication reconciliation and assistance with post-discharge follow-up plans. Nurses communicate with the patients’ outpatient providers to help facilitate the hand-off from hospital to medical home. After discharge, the nurses call the patient and caregivers at home to check in about medications, symptoms, function, and follow-up and utilize coaching techniques to assist the patient and caregiver to make healthy choices. If urgent interventions around medications or service needs are identified during the phone call, the nurses consult with inpatient and ambulatory providers to come up with a safe and appropriate plan of care.

The SHHE team has enrolled 700 patients. The results will be analyzed and published sometime in the next year comparing outcomes between the intervention and usual care groups. In the meantime, the intervention has been widely accepted by hospital leadership and front-line staff and is being embedded into the routine transitional care. As CMS begins to fund more options for transitional care such as the Community Care Transitions Project, the hope is that the SHHE Project will become part of a menu of culturally and language appropriate interventions available to SFGH patients.

For more information, please contact the Project Coordinator, Eric Kessell, at EKessell@medsfgh.ucsf.edu.

Meet the SHHE Team!

Jeff Critchfield, MD

Sue Currin, RN, MS

Michelle Schneidermann

Eric Kessell is the Project Coordinator for Support to Hospital to Home for Elders. He holds a Ph.D. in epidemiology from the University of California-Berkeley and completed postdoctoral training in the Community Academic Research Training Alliance (CARTA) in the UCSF Department of Psychiatry. His research interests include the relationship between neighborhoods and mental health, health services research in underserved populations, and health care payment reform.

Barbara Walter RN, MSN, PHN; Supports the role of Sue Currin on this project and serves as RN Clinical Coordinator for Support from Hospital to Home for Elders. Ms. Walter received her MSN in Health Policy from UCSF School of Nursing with an emphasis on “Access, Affordability and Reduction in Disparities in Outcomes”. Her career includes clinical and administrative positions in ambulatory and acute care environments.

Richard Santana is a registered nurse with the City and County of San Francisco, with experience in Acute In-Patient Psychiatry and Med/Surg in Trauma. He is the Latino Focused Transitional Care nurse, trained in Motivational Interviewing. Richard’s passion is to advocate for the most vulnerable of the community with an emphasis in implementing patient-centered preventive education. Richard presently co-chairs the Ambassadors of Nursing Excellence and is a member of the Professional Development Practice Council of SFGH Nursing Shared Governance.

Catheryn Williams is a registered nurse and has been with the City and County of San Francisco for over 17 years. Ms. Williams has a deep connection to the community as she was born in San Francisco General Hospital. As well as the many years of experience and knowledge of our patient population, she offers an authentic perspective and an innate ability to foster a therapeutic alliance with the patients of SFGH. In addition to her dedication to the community, Ms. Williams’ passion also includes fostering and mentoring through her teaching experience as an Assistant Clinical Instructor for the City College Registered Nursing program as well as a Preceptor for the Med/Surg units at SFGH. Ms. Williams is also a member of the Cultural Understanding Task Force.

Tip Tam is a registered nurse with the City and County of San Francisco. Ms. Tam is the Asian focused nurse. She began her nursing career in the Adult Day Care Services. Understanding the need for bilingual nurses, Ms. Tam was inspired to continue her path in nursing to represent patients in which Cantonese and Mandarin is their first language. Ms. Tam continues to advocate for the most vulnerable by implementing education in which the patient is empowered to succeed in managing their illness.

Alexandra Velasquez is one of the bilingual (Spanish/English) research assistants for the Support to Hospital to Home for Elders (SHHE) Study. Alexandra graduated with a BS in Psychology with a Biology emphasis and a minor in Social and Ethnic Relations from UC Davis. She previously worked in a study looking at diabetes and acculturation. At UC Davis she was the project manager for a research study titled "Health, Service Use, and Aging in Older Latinos". At Stanford she co-translated the Geriatric Depression Scale (GDS) to Spanish, Salvadoran version. Alexandra has done volunteer work in India, Nicaragua, and community clinics here in the US. Her research interests include health care disparities, language barriers, and educating and empowering underserved populations. Alexandra will continue to foster these interests as she moves forward in her education either in public or global health.

Wayne Liu is a Staff Research Associate for the Support from Hospital to Home for Elders research project. He holds a BA in Psychology and a BS in Human Development from the University of California, Davis. He also teaches 4th grade Chinese school at a Chinese Bible church and speaks three different Chinese dialects (Cantonese, Mandarin, and Toisanese.) Wayne joined the project with an interest in helping underserved populations understand how to prevent hospital readmission.