2011 Nursing Annual Report - FINAL.pub - South Shore Hospital

InnovationsTransforming Care for South Shore Medicare PatientsIn 2011, South Shore Hospital(SSH) and the South Shore VisitingNurse Association (SSVNA),the region’s largest provider ofhome health services, collaboratedwith two local organizationsto streamline healthcare forMedicare patients and help reduceunnecessary hospital readmissions.The South Shore Community CareConnections initiative represents agroundbreaking collaborationamong community health careproviders and service agenciesthat will fundamentally transformthe model of care for Medicarepatients in Southeastern Massachusetts.South Shore Hospital, along withSouth Shore Elder Services(SSES), the primary area agencyon aging which coordinates resourcesand programs for elderpatients on the South Shore, andHarbor Medical Associates, oneof the region’s largest primaryand specialty physician practicesserving residents across the Hospital’sprimary service area, submitteda grant proposal to Medicareand Medicaid Services (CMS)to request funding for CommunityBased Care Transition Programs.The South Shore Community CareConnections proposal sought toaccomplish the goals of the programthrough the implementationof three fundamentalchanges in the current caremodel: Advanced in‐hospital risk assessmentlinked directly withtiered post‐discharge services. The creation and expansion ofnew roles within the individualpartner organizations that areexplicitly designed to coordinatecare across setting transitionswith the clear, commonobjective of avoiding rehospitalization. Establishment of a commoninformation technology infrastructurethat enables sharedidentification of at‐risk patientsand sharing of relevantdata to coordinate care acrosssettings.While the grant proposal was notsuccessful, this project broughttogether a team of communityhealthcare providers and serviceagencies across the South Shoreregion of Massachusetts thatrepresents the spectrum of caresettings experienced by the vastmajority of Medicare patientsstruggling with conditions thatcan often lead to readmission.The South Shore Community CareConnections initiative providedthe opportunity to collaboratewith our community partners,generate forward‐thinking ideas,and change how we – as an organization– look at our care deliverysystem. Several contemporaryideas are already being incorporatedinto practice within theexisting funding capacity of theseorganizations.41