Critical Path Network

Web site links to valued post-discharge resources

On-line information replaces piles of documents

Instead of handing patients piles of papers during the discharge planning process, case managers and social workers at The Valley Hospital in Ridgewood, NJ, simply refer them to the hospital's Valley C.A.R.E.S. web site, a resource with links to more than 2,000 agencies, facilities, organizations, and informational sites.

Valley C.A.R.E.S. is the brainchild of social worker Karen Barbato, MSW, and Molly Schenk, office supervisor for the case management/social work department. They initiated the project, planned it, did the research, and worked with Ken Parker, manager of marketing and communications, to set up the on-line resource. The acronym stands for Community Access Resource Education System.

"This project streamlined work processes and organized information in one place. It's a tremendous resource for patients and family members because it has everything related to discharge planning and finances at their fingertips, whether they are in the hospital or a family member in another state," says Maryann Vecchiotti, director of case management/social work.

Impetus for project

The project was developed when Barbato and Schenk volunteered to update the packets the hospital gave to families with information about long-term care options. As they went through the information on hand, they discovered that much of it was out of date and some of it had been copied so many times, it was hard to read. The team wanted to create additional packets for other types of patients, such as maternity patients or people with disabilities and started writing down the categories of packets and the type of information they wanted to include.

"We realized it would cost an exorbitant amount of money to make copies and people would still get information they wouldn't need but they might not get information they would find useful. Then, we still would be challenged to update the information frequently and discard the old information," Barbato says.

Barbato and Schenk began by listing the topics they wanted to list on the web site, what details they wanted to include on each one, and how they should link together.

Major categories include bereavement services, caregiver resources, community resources, disability programs, discharge planning information, end-of-life care, long-term care services, maternal/pediatric/adolescent services, medication assistance programs, mental health and emergency services, senior services, support groups, veterans' services, and health organizations and agencies.

Schenk researched the Internet to identify links that should be included for each topic, starting with the department's internal resource list. Barbato wrote the introductory section for each topic.

"It's a compilation of everything the hospital staff have collected as a group. It's been extremely helpful because the web sites are frequently updated so we always have the latest information," Schenk says.

The hospital's webmaster set up a way that they could look at the web site offline, proofread it, and check the links. "We took a long time developing it because we wanted it to be correct, comprehensive, and attractive," Barbato says.

Five of the largest post-acute health care centers in the area donated $50,000 to fund the project.

"As soon as we showed them what we wanted to do, they were eager to be a part of it," Barbato says.

Putting information to work

The purpose of the project is to shorten the time and improve the efficiency of the discharge process by offering families research capabilities that enable them to access information that is pertinent to them without having to wade through pages of information, Barbato says.

"Our goal is to try, in a concise way, to lead a family through everything that we discuss face to face — to show them the process, their choices, and what they need to do," she says.

The webpage is especially useful for family members who live in other parts of the country and can't spend a lot of time visiting nursing homes or assisted living centers, Barbato says.

"In the past, we sent them a list that said, 'Bergen County Nursing Homes.' Now we send them a link that allows them to tour the nursing home web sites and get an idea of what the facilities are like as well as check the nursing home reports cards," she says.

The daughter of one patient who has dementia wanted to place her mother in a long-term care facility closer to her home in New York. Barbato helped the daughter go on-line, identify potential facilities, and download a checklist of what to look for in a facility. In the case of another patient, who was failing at home, Barbato was able to direct the family to caregiver resources, education and support groups, and adult day care facilities.

"When I talk to someone on the telephone and they can't be here, I send them an e-mail that includes links to the various parts of the web site they may find useful," she says.

The social workers and case managers guide the family members through the process if they aren't familiar with computers or the Internet. As soon as the hospital's wireless Internet network is complete, they will be able to take laptop computers into the patients' rooms and show patients and family members discharge options at the bedside. In the meantime, the hospital has set up a computer kiosk in one of the waiting rooms, giving family members access to the information.

"Sometimes I bring them into my office if it's convenient and they're not computer-savvy. Other times, if they just want to sit down and look at it, I walk them to the computer station and show them how to get started," she says.

Web site cuts phone calls

Having an on-line resource has cut down on calls from physician offices and the public who are seeking resource information, said Schenk, who handles telephone calls from the public.

"We were being inundated with calls from doctors' offices who wanted our home care list, our nanny list, or community support groups. Now the doctors can print out information from our web site or give their patients a card with the web site information on it. We can refer the public to the web page for the information they need," Schenk says.

Feedback has been positive from patients and family members, physicians, and especially from the hospital staff, Barbato says.

"It gives staff members centrally located and accessible up-to-date information and resources, saving them time and making the discharge process more effective," Barbato says.

(Editor's note: For more information, contact Karen Barbato, MSW, social worker, The Valley Hospital, e-mail: