Helping hands after surgery or hospitalization

When Neal Gordon of Yarmouth was discharged from Cape Cod Hospital in June 2024 after a heart attack, angioplasty and stent placement, he was surprised and reassured to receive a phone call a couple days later from Birgit Weisshuhn, RN, BSN, an ambulatory case manager with the Cape Cod Healthcare Helping Hands Program.

“Birgit introduced herself, asked me how I was doing, was everything going alright and if I had any questions,” said Neal. “She reviewed all my medications, the procedure I had, and reviewed the steps I should take if I experienced any chest pain. She went over everything.”

Weisshuhn also asked him if he needed help with making appointments for follow-up visits, according to Gordon’s wife Judy, who is a retired emergency room nurse. Gordon assured Weisshuhn that his wife could handle it, but said he would call if they needed any help.

Helping Hands is a skilled team that supports ‘ambulatory-sensitive conditions,” which are health conditions that with management, treatment and interventions can prevent hospitalizations, especially readmissions, explained Jamie Bartz, senior manager of case management operations.

The team includes six medical case managers, two behavioral case managers who are social workers, a registered dietitian, and two navigators, added Coral Zine, RN, CCM, who has a BS in psychology and is the PHO (physician hospital organization) ambulatory case management supervisor.

How to Receive Services

Helping Hands is a part of the Cape Cod Healthcare Accountable Care Organization (CCHC ACO), also known as the physician hospital organization (PHO), said Bartz. The PHO is a partnership between Cape Cod Healthcare and Cape Cod Preferred Physicians and works with insurance companies, including commercial risk contracts and Wellsense Community Alliance.

To receive services from the Helping Hands program, patients must have a Cape Cod Preferred Provider, be a member of one of the risk contracts and have a qualifying diagnosis.

To self-refer for services or for further information, call 508-862-5505 or fax 508-862-7491.

List of Services

The services Helping Hands staff provide, according to Zine, include the following:

• Case managers coordinate care for patients' post-hospital discharge and also help patients manage their chronic conditions.
• The navigators work mostly in the emergency department at the hospital doing patient screenings to assess their needs and connect them with medical/behavioral or community resources.
• They also educate patients when it is appropriate to go to the emergency department versus their primary care physician.
• Following up with patients post hospitalization usually lasts about one month and chronic care management lasts about one to three months.
• Case management also oversees a diabetic program that helps patients lower their A1c and guides them to close gaps in their care such as making an appointment for a diabetic eye screening with an ophthalmologist or other testing they may need.
• Behavioral health case managers who are licensed social workers who work with post hospitalized and referred members with behavioral health of SUD (substance use disorder) needs to develop a behavioral health care plan, provide education and resources to ensure follow-through with medications, provider appointments and crisis plans. One of the behavioral health case managers also specializes in pediatrics.
• The registered dietician is also a certified diabetes educator who works closely with case managers and providers to help patients with their nutrition, especially those with diabetes and cardiovascular disease through education and goal setting.

Grateful for Services

Both Bartz and Zine say they find their work very rewarding.

“I’m not a clinical staff person because I am focused on operational workflows and reporting, but it is really nice to see the team impact patient care and make a difference,” said Bartz.

“It’s about making a difference in everyone’s lives by keeping the patient healthy and in their home, which is where they want to be and is one of our goals in addition to preventing a hospital admission that may not be needed,” added Zine.

Neal and Judy Gordon said they are grateful the services are available if they need them in the future.

“It is such a great service for people who don’t know what to do and don’t know where to go for help,” said Judy. “I believe everyone needs an advocate when you reach a certain age and to me it is unbelievable that they offer this service.”