01/30/2018

St. Joseph’s/Candler launches new home health program to educate and empower patients with chronic or progressive conditions

St. Joseph’s/Candler Home Health Care offers many services that facilitate patients’ improved health and wellness in the comfort of their own homes.

For some, home health care is only needed for a short amount of time and then they are on the road to recovery. But others with chronic or progressive illnesses, such as congestive heart failure or COPD, usually require more intensive and different types of care to better understand and manage the progression of their illness and what they need to do to stay out of the hospital.

Kathleen Benton
Kathleen Benton, DrPH, MA, Director of Clinical Ethics and Palliative Care

For these patients, St. Joseph’s/Candler Home Health Care, the only Joint Commission Accredited Hospital owned home health agency in the area, has launched the Progressive Illness Management Program. The program targets patients with chronic conditions and provides the education, tools and support to keep patients at home longer and to avoid readmission and long stays in the hospital.

“We know patients have better quality of life and a more healing environment at home. The goal of the program is to help critically chronic patients with the extra support they need,” says Kathleen Benton, DrPH, MA, Director of Clinical Ethics and Palliative Care. “We want to help patients who are likely to unnecessarily readmit for symptomatic issues to understand earlier the progression of their disease and set boundaries and goals for what will embrace their quality of life.”

The Progressive Illness Management Program is for patients who qualify for SJ/C Home Health Care and have a chronic condition. Examples include congestive heart failure, COPD, end-stage renal disease, a cancer diagnosis that requires home support or a combination of chronic diseases or conditions such as heart disease and diabetes.

Related Article: How do you know if you or a loved one qualifies for home health care?

The program is not an end of life program. In fact, one of the main goals is to start working with patients and their families early in their disease process through skilled intervention and education.

“We are really looking to help patients who are very early on in their disease,” Benton says. “We want to help them control their condition, help improve quality of life, help them at home and change this culture of missed communication. The current culture of conversation supports no discussion until the end stage of disease when death is likely imminent. Patients deserve a better understanding of their illness and whole-person support much earlier.”

The SJ/C Home Health Care team, including nurses, therapists, aides and social workers, receive on-going training in identification, assessment, treatment and care of patients best suited for this program. The Progressive Illness Management Program is for patients where home health care is medically necessary. The program has many facets that include:

  1. An approach for patients in the early stages of a chronic condition; and
  2. Those who have dealt with their conditions much longer and are having a hard time staying out of the hospital.

“The value of this program is implementing a very emotional and productive conversation early in an illness when the patient is more capable of emotionally digesting it,” Benton says. “Most of these conversations either only happen with the family, excluding the patient who may be unable to converse at that given time, or they come when the patient is too scared to process the situation and too sick to set goals.”

Once those initial conversations take place, the program is set into motion. Patient and caregivers will be followed closely. Members of the home health team will provide the tools, instruction and support to improve the patient’s quality of life. Those individuals that require even more care will be referred to a pain and symptom management physician through the Steward Center for Palliative Care in Savannah. Additionally, an assessment will be made in order to connect patients with community resources through the help of social work services and the Edel Caregiver Institute.

The physician or nurse practitioner will come to the patient’s home and make symptom management recommendations and provide other support, Benton says. For example, the physician may be able to help the patient control symptoms, such as shortness of breath or nausea, at home rather than a visit to the emergency department.

Additionally, the patient will continue to see his or her primary physician and/or specialist. The pain and symptom management physician will work in coordination with the primary care physician regarding any changes in management.

“When patients are at the point where they are jumping from one hospitalization to the next and from one specialist to another, they need to realize there is something additional out there and there is more support available,” Benton says. “I would say that it is never too early to just have a discussion. I think patients tend to treat these types of discussions with natural avoidance, but it only makes it more difficult. It’s never too early to wonder, ‘What is our plan?’”

The Progressive Illness Management program does require a referral from a doctor. If you or a family member think that this program is right for you please call us for more information at 1-800-942-5232 or visit our website

  • St. Joseph's Hospital Campus: 11705 Mercy Blvd., Savannah, GA 31419, (p) 912-819-4100
  • Candler Hospital Campus: 5353 Reynolds St., Savannah, GA 31405, (p) 912-819-6000
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St.Joseph's Hospital Campus: 912-819-4100

Candler Hospital Campus: 912-819-6000