One Year, 100 Patients: Changing Lives at Continuing Care

When Zach aged out of his network of providers after suffering a traumatic brain injury when he was a teenager, finding a whole new network was difficult, until he met Dr. Mary Stephens.

At age 17, Zach suffered a traumatic brain injury. This would prove to be a defining moment in Zach’s life, the first of many. The second defining moment, as Zach’s mom Cheryl will tell you, came years later, when at age 21, Zach aged out of the entire network of providers, specialists and rehab therapists that he had spent the last four years working with.

Feeling lost, Cheryl searched high and low across the region for a program that could provide an adequate level of care for Zach’s medical complexities. At one time, Zach was a patient of four different healthcare networks, which only added to Cheryl’s headaches. It was Zach’s first visit with Dr. Mary Stephens, as the first patient in Jefferson’s Continuing Care Program, that finally offered long-awaited relief.

“We needed exactly what their program offers,” Cheryl said, “And it wasn’t available to us at all anywhere else.”

Dr. Stephens met all of Zach’s needs, as well as needs that he and his family didn’t even know they had.

“We felt lost until we found Dr. Stephens. She knows Zach well enough now that she can troubleshoot things without us having to drive in,” said Cheryl. “She’s also gotten us in contact with other docs at Jefferson who can communicate closely with her to collaborate on Zach’s care.”

Many of our families have had doors shut on them. They’ve been told that their child’s case is ‘too complicated,’ or that ‘we don’t take that type of patient.’

—Dr. Mary Stephens

Cheryl is no longer left feeling like she’s trying to figure things out on her own. The program’s support team helps her understand which of Zach’s medical needs should be addressed immediately and which can be monitored.

“There are so many doctors trying to find the best level of care for Zach, which is one of the things that makes me feel good about this program,” said Cheryl. “They’re constantly asking how we can keep helping Zach to feel better and how we can keep advancing his recovery journey.”

Dr. Stephens’ goal for the Continuing Care Program is to create a primary care home for an underserved population of patients—those with complex medical needs that require acute, specialized care—in order to improve their quality of life, as well as their families’. In its first year, the program’s holistic approach to care has already provided life-saving interventions to many of its 100 patients.

“Many of our families have had doors shut on them. They’ve been told that their child’s case is ‘too complicated,’ or that ‘we don’t take that type of patient,’” said Dr. Stephens. “We pride ourselves on having an open-door system where people feel welcome, and can get all of their healthcare needs met.”

Within the program, Dr. Stephens has also implemented steps to make sure that a patient’s family can receive care at Jefferson—care that they often neglected before.

“Caregivers face high levels of stress,” explained Dr. Stephens. “And they often neglect their own healthcare needs because they’re so focused on their loved ones.” The goal of providing a new level of care and support fueled the decision to provide primary care to family members.

For families like Zach and Cheryl, it’s the little things that make a difference.

“It makes all the difference to have a physician that listens,” said Cheryl. ”I just feel like having Dr. Stephens and the rest of the team at the Navy Yard has helped to alleviate so much of the stress.”

The Continuing Care Program is celebrating one year in operation and is dedicated to changing lives now and far into the future. It has recently expanded its offerings to include the ability to conduct new and established patient visits via telehealth, minimizing the need for high-risk patients to travel to the office to receive the care that they rely on.

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