By Erika Kengni
A local nonprofit is expanding a program that aims to bridge the gap for people who do not need hospice care but require extra support.
Patients in ConnectionsPlus Hospice and Healthcare’s Advanced Illness Care program receive the support of a nurse practitioner, a care navigator and a care counselor, said Christina Brizendine, the former director of the AIC program. The care navigator connects patients to resources such as transportation and food assistance.
Those in the program receive regular home visits from team members who can help them make sense of information from different specialist doctors, said Tasha Walsh, the CEO of ConnectionsPlus.
Because ConnectionsPlus is a nonprofit, the AIC program is completely free, Brizendine said. The organization is working to get coverage for the AIC services through Medicaid and private insurance companies.
“It really started with psychosocial support for the patient and their caregivers,” Walsh said.
The program started in 2021 but has been expanding since ConnectionsPlus merged with Mountain Regional Hospice in Alleghany County. ConnectionsPlus now serves Alleghany and Bath counties, as well as Rockbridge.
One of the goals of the AIC program was to cut down on emergency room visits, according to Walsh.
“A lot of the time what happens with advanced illnesses is people start to panic when they experience symptoms and that is really not the best use of the emergency room,” Walsh said.
In the AIC’s first year, patients in the program reduced their visits to the emergency room by over 70 percent, Walsh said.
“It really started with psychosocial support for the patient and their caregivers”
After the first year, the AIC expanded to include a medical component, said Walsh said. Recently, three staff members were added to the program in preparation for community outreach efforts this spring.
Last September, ConnectionsPlus hired a program director and an office manager for AIC, according to Brizendine. And in December a care counselor was hired.
The sole nurse in the program might see as many as 12 patients a day, according to Brizendine, who is now the Director of Volunteers for ConnectionsPlus. Not all patients require a counselor, so the counselor has a smaller caseload.
There are currently almost 60 patients in the program, said Bob Capito, the current director of the AIC.
Walsh said that there is a lot of demand in the community for advanced illness care.
In addition to medical and psychosocial care, ConnectionsPlus works with other organizations in the community to help patients who are food insecure or need transportation.
Valley Area Stretcher Transport (VAST) works with ConnectionPlus in the event that patients need to be transported via stretcher, according to Michelle Watkins, the director of VAST.
For Medicare patients, VAST’s services are free, but those without insurance can expect to pay $250 each way, Watkins said. As a nonprofit, VAST works to keep costs manageable.
This summer, ConnectionsPlus plans to implement a new model for treating people with dementia and Alzheimer’s disease, said Brizendine.
The “Guiding an Improved Dementia Experience” (GUIDE) model was rolled out by Medicare in 2024 and aims to support dementia patients and their unpaid caregivers, according to the Centers for Medicare and Medicaid Services. The GUIDE model includes a “comprehensive package of care coordination and care management”.
The GUIDE model is “very regimented” and required the hiring of a care coordinator and a care counselor, said Capito.
ConnectionsPlus plans to hire more staff for the AIC program to meet the GUIDE model requirements set by Medicare, said Brizendine.
“We’re working real hard to get our team together,” said Capito, “So that we can walk beside [patients] in their journey.”