At a recent national webinar, Sue Devoe, RN, BSN, Director of Quality, Licensing and Accreditation at Northern Maine Medical Center (NMMC), and Sharon Berz, Director of Long Term Care at the Aroostook Area Agency on Aging (AAAA) were guest presenters to a national audience of peers on a partnership the two organizations created to support patients in the transition from hospital to home. Implemented nearly two years ago, the partnership of NMMC and AAAA was intended to improve the quality of life of patients, to assist them to thrive in their home and to reduce readmission to the hospital.
At the outset of the presentation, Berz captured the attention of the audience by sharing a compelling story which she described as the trigger for development of the partnership. She recounted what she described as, the final straw, of the traumatic story of a disabled senior citizen in Aroostook County who was found in his home literally frozen to death last winter because he ran out of fuel to heat his home. His caretaker/sister was hospitalized herself at the time, leaving the elderly man without resources. Berz affirmed what was on everyone’s mind about how this should never be allowed to happen in our backyard.
The start of this work began two years ago when NMMC recognized the value of offering patients who are discharged from the hospital a courtesy home visit.
With the complexity of navigating the healthcare system and the importance of patients understanding how to manage their care, NMMC sent a Registered Nurse (RN) into the home for one courtesy visit within three days of discharge from the hospital. The initial focus for the program was to offer patients and family members support in understanding and managing their medications. In addition, the home visit is an opportunity for patients and family members to ask questions they may not have remembered to ask during the hectic time of discharge from the hospital. In the home, the RN reviews medications and fills pill boxes if necessary, checks vital signs, ensures that the patient received a follow up appointment with their provider, checks on transportation availability to get to their appointment and confirms they have filled new medication prescriptions.
A few months after NMMC launched its program, it received the attention of AAAA and a dialogue began, which Devoe and Berz refer to as “the start of a beautiful collaboration” which has resulted in benefits to patients in the form of safety, knowledge and reduced frequency of hospital readmissions. Early in the partnership AAAA provided onsite training for NMMC RN’s on the process for performing environmental assessments in the home. The evaluation includes the assessment of: barriers for entering or exiting their home, heat source, food supply, environmental safety for prevention of slips, trips and falls and sanitation concerns. If any concerns are identified, a referral is made to AAAA who will explore available programs to assist the patient. With the presence of the RN’s in the home, the assessment of the environment extends the reach of AAAA personnel who would not otherwise have information about patient needs.
The strategy of providing meals and a safety assessment has enhanced the quality of life of patients by offering resources to keep them thriving in their own homes. For the months of January to June of 2016, acceptance of meals ranged from eighteen to forty percent of patients accepting a home visit from an NMMC RN. During that same period, 2.4% of patients who accepted a courtesy home visit were readmitted to the hospital, where double that amount was readmitted who did not accept the home visit. The NMMC courtesy home visit program does not replace any other outpatient service; the program is intended to supplement and to offer an additional safety net for patients who are vulnerable after discharge from the hospital.
The holistic approach for safe transitions from hospital to home is a partnership which assists patients to stay healthy and to stay at home. The collaboration between NMMC and AAAA is now beginning to demonstrate the long term benefits for patients. The partnership and improved communication with providers across the continuum has facilitated the identification of gaps in services needed in the home for patients not only to heal, but also to thrive. To learn more about NMMC’s courtesy home visit initiative, call 207-834-1509.