San Diego City Wire

A medical team in San Diego County, comprising public health nurses and paramedics, is providing in-home follow-up care to patients recently discharged from Sharp Grossmont Hospital. The initiative, which began as a pilot program in June 2023, has been extended for another year with plans for expansion. This collaboration involves the County, Grossmont Healthcare District, and Sharp Grossmont Hospital.

Prior to the program's launch, 12% of patients were readmitted to the hospital within 30 days of discharge. Since the program started, this rate has decreased to 4% among participating rural residents. The team visits patients once a week over a 30-day period to provide medical tools and education.

County public health nurse Amy Dull highlighted the positive impact on rural communities: “One of our very first patients at the beginning of the program, he was just in awe that the program would travel so far out there to see him and check on him."

Nick Johnson, a CAL FIRE/County Fire captain paramedic involved in these visits, emphasized patient empowerment: “We give them tools to make them more self-sufficient.” He also checks for fire risks and installs smoke detectors if needed.

The program also addresses social isolation by connecting patients with community resources like YANA (You Are Not Alone). Dull noted, "It’s nice to establish these relationships with people. I think it means as much to us as it does to them.”

This initiative aims to reduce disparities faced by rural residents due to longer travel distances or economic challenges. It is modeled after an urban-focused healthcare district program and involves multiple agencies including San Diego County Fire and San Ysidro Health.

According to Amy Abrams of Grossmont Healthcare District: “This program exemplifies the power of public-private partnerships in addressing critical healthcare challenges while also demonstrating cost-effective solutions that benefit the entire healthcare system.”