“I’ve gotten to go on a few home visits,” said Joanne Fortin, RN, director of service excellence and
communications. “Patients are so anxious to go home, they think they’ve got it. They can handle it, but when
they do get home, it’s a different story and they really benefit from sitting down (with someone) in their own
home.”
The nurse will also do a safety assessment, looking for things like loose rugs that can cause a fall. And the
nurse will do a medication reconciliation, comparing what has been prescribed with what the patient is actually
taking. Medication errors are avoided this way.
Much of NMMC’s readmission prevention program is
focused on preventing medication errors. Pharmacists
participate in the daily interdisciplinary team meeting.
They also try to visit all hospitalized patients to instruct
them about their medication regimen.
The hospital is also working with local retail pharmacies
to deliver prescribed medication to patients as they are
leaving the hospital thus saving them a trip to the drug
store.
Other discharge services the hospital offers include
referring patients to the Aroostook Area Agency on Aging
(AAAA) to see if the patient qualifies for any of their
services. And the AAAA, through a grant, has provided
the hospital with 14 frozen meals that it can give to each
patient to take home as they leave the hospital. A recent
CMS pilot program in Florida that provided free meals to
elderly patients at discharge reduced rehospitalizations.
“There’s a whole psycho/social aspect you can’t ignore,”
Bois said, adding that in the old days when an older person
was discharged from the hospital, he or she had family around, either at home or nearby, to step in and help the
patient with something as simple as a nutritious meal. “Now family members are spread out.”
Preventing readmissions is good patient care, Devoe said, “You hate to see these folks come back
(unnecessarily).”
Katherine Fortin, RN, checks James Bossie's blood pressure
at his home in Cross Lake. Such home visits after
hospitalization can prevent readmissions.
Northern Maine Medical Center
