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

InnovationsHome Care Division Participates in New Medical Home PilotIn 2011, the Home Care Divisioncollaborated with communitypartners on innovative ways toimprove care outcomes for ourshared patients. On August 8,2011 we began a 90 day MedicalHome Pilot with South ShoreMedical Center. The goal of thepilot was to decrease emergencyroom visits, hospitalizations, andcosts for a select group of highrisk, medically complex patients,and to help them remain ashealthy as possible in their homeenvironments.Two VNA nurses, CherylSilipigno, RN, Home Care Practitioner,and Eileen Cleary, RN,VNA Team Leader, were selectedto be care coaches during the trialand together managed 17 TuftsMedicare Preferred patients forSouth Shore Medical Center. Thecare coaches made home visits,provided telephonic management,and coordinated care for thesepatients twenty‐four hours a day,seven days a week.The care coaches also assistedpatients with tasks as simple asarranging rides to appointments,as well as more complex taskssuch as medication reconciliationin order to provide a single sourceof truth for all providers.The care coaches worked collaborativelywith South Shore MedicalCenter, skilled nursing facilities,other VNAs, Elder Services, hospitals,and a multitude of other communityproviders to ensure thatthe patients received the best,most cost‐effective care to assistthem in remaining as healthy aspossible in their homes.The trial was a huge success andnext steps include continuing thismodel in an Accountable CareOrganization structure in FY12 for3,700 managed medical patientsof South Shore Medical Center.Pictured at left: Cheryl Silipigno,RN, and Eileen Cleary, RN, whowere selected to be care coachesduring a new medical home pilotprogram.43