Every year, the Alliance recognizes the most innovative home care programs in the state. Nominate someone for the 2015 awards.
Past award winners are proudly displayed below.
The “One Cape” Jouney to Meet the Triple-aim and Decrease Readmission Accross the Continuum
Submitted by: VNA of Cape Cod
Reducing readmissions to hospitals for high risk elders is hard work. Even once variables are identified, it takes a multi-disciplinary, cross sector approach to really make a difference. The One Cape project has been a shining example to the state of how that can happen and what results can be achieved. Of particular note in terms of driving smooth cross continuum transitions, has been the work of the VNA with area skilled nursing facilities, including developing processes for direct admissions from home care into the nursing home in cases were homecare proves insufficient to prevent deterioration. The addition of physicians to the cross continuum teams has added additional depth to readmission case reviews examining issues such as: was follow-up appropriate for patient’s condition and what could have been changed.
Memory Loss Program
Submitted by: Community Nurse & Hospice Care
A diagnosis of a Memory Loss illness can be devastating for a patient , as well as for her/his family. At Community Nurse & Hospice an idea to pursue grant funding to support training for home health aides to provide care and family respite for patients with dementia and other diseases, has grown into a community wide program of supporting clients with Memory Loss, with both in home and community based activities. The Memory Loss program includes a well-trained interdisciplinary team capable of providing assessment, education, caregiver support, care navigation/planning, resource assistance, respite, counseling, occupational therapy, complimentary therapy and a 24 hour hotline. Each plan is customized depending on patient and family need and disease progression. All referrals receive a complimentary assessment visit and services are provided to all those in community, with or without financial means.
Story Corps Legacy Project
Submitted by: NVNA
NVNA is the first and only home care entity in MA participating in the national
initiative known as Story Corps. Initiated at NVNA by the Palliative Care Coordinator, the project records patients stories, memoires, wishes and legacies for generations to come. The family is provided a CD and a copy is sent to the American Folklore Center at the Library of Congress for archiving. The project is now an agency wide initiative incorporating home health, hospice, and private care service lines, as well as community support groups. The program is run with the help of volunteers, who find the program opens patients and families to have conversations that might not have otherwise occurred and share pieces of history that would be lost.
Award For Innovation in Palliative Care
Submitted by: VNA & Hospice of Cooley Dickinson
Changing demographics and advances in technology have seen a rise in patients with multiple co-morbidities, complex illnesses, and treatment plans. Such patients generally experience poorly coordinated care and repeat hospitalizations, often related to pain and symptom management. Many of these patients are in clinical, functional, and/or nutritional decline, but are not ready, eligible, or interested in hospice.
VNA & Hospice of Cooley Dickinson’s Palliative Care Program provides high quality, coordinated, and compassionate services to its patients. Its interdisciplinary team builds close relations with the patient, family, and the primary care provider and helps patients reach their health and quality of life goals. Among the program’s features are:
- Strong presence and skills by rehab clinicians;
- Nurses with Hospice & Palliative Care Certification;
- Social work referral for all Palliative Care patients;
- Oversight by RN & MD leaders certified in Hospice & Palliative Care; and
- Executive Leadership support to invest in ongoing growth of team members.
Critical to the program has been clarifying and communicating to VNA & Hospice staff and collaborators the patient selection criteria for the Palliative Care Program as distinct from both routine home care services and hospice services, which are both provided under the Medicare Part A . Since its inception, the program has seen steady growth and high patient and family satisfaction.
In addition to leading locally, members of the Palliative Care team have become statewide advocates for advancing home care based palliative care, presenting at numerous conferences, including a webinar for physicians coordinated with the Mass Medical Society.
Award For Innovation in Home Care Nurse Residency
Submitted by: VNA of Boston
The growing demand for home based care makes it imperative that home health agencies act to prepare more nurses for roles in home care. Typically, newly graduated, licensed registered nurses are not considered for these positions. The Home Care Nurse Residency Program, a joint effort between the Visiting Nurse Association of Boston (VNAB) and Simmons College School of Nursing, is changing this. With support from a grant from MA Board of Higher Education, the Nurse Residency program was developed to:
- Provide newly graduate registered nurses support and experiences to become competent home care nurses.
- Proved current VNAB nurses opportunities to increase their skills as preceptors for residency nurses.
- Provide resources for other academic-service partnerships to use to replicate this model
The initial pilot was an enormous success. All of the residency nurses successfully completed orientation and probation at faster speeds than typical newly hired nurses. All of the residency nurses remain employees of the VNAB in either full time or per visit positions.
VNAB’s innovative approach to meeting the growing demand for skilled home health care nurses is serving as a model for many other organizations facing the same challenge. A tool kit was developed and made available to interested agencies. The kit includes materials used in recruitment of nurses to the program, curricular materials for the preceptor development course, and preceptor/preceptee competency checklists.
The Home Care Nurse Residency Program model has been presented to more than 40 home care agencies in Massachusetts. At least two are in the process of replicating the model. VNAB is currently hiring a second cohort of newly graduated nurses. Three began in February 2014, and two more are on track to start in April.
Award For Innovation in Early Adoption of the Mass HiWay
Case 1: Care Management of Heart Failure Patients at Admission and Post-Discharge, Baystate VNA & Hospice
In partnership with Baystate Health, RiverBend Medical Group, Mercy Medical Center/Sisters of Providence Health System, Baycare Health Partners, and Valley Medical Associates, Baystate Visiting Nurse Association & Hospice has begun using the Mass HIway and a Pioneer Valley Health Information Exchange (PVIX) to show how technology can be used to impact the care of heart failure patients at admission and post-discharge. Additionally, they are demonstrating how information sharing and communication alignment among competitors can be accomplished for the benefit of the patients they share. This project includes:
- Transition of Care Alerts: transmit an alert to the primary care provider, care manager, visiting nurse, and/or cardiologist that their heart failure patient is under evaluation in an ER or has been admitted to acute care
- Collaboration and Information Exchange: deliver a comprehensive medication and procedure lists to the acute care setting to facilitate effective and accurate medication reconciliation and to mitigate redundant testing
- Care Plan Dissemination: at discharge, route Care Plan and Discharge Summary through PVIX and the HIway back to primary care provider, care managers, and/or post-acute
- Medication Adherence: at discharge, route Care Plan and Discharge Summary through PVIX and the HIway back to primary care provider, care managers, and/or post-acute facility to ensure proper follow-up care and management.
The result better: communication, collaboration, and information exchange about a heart failure patient.
Case 2: Discharge Summaries from Acute Care to Home Care, Gardner VNA
In partnership with Heywood Hospital, the Gardner Visiting Nurse Association (GVNA) is strengthening their cross continuum collaborative network by improving the coordination of clinical information exchange for post-discharge patients residing in North Central Massachusetts. Using the MA HiWay and the LAND gateway, GVNA‘s focus is on electronic exchange of patient information, especially lab results, as a way to demonstrate improved patient outcomes with a potential reduction in emergency department visits or hospital readmissions.
This inter-collaborative project increases the amount and accuracy of information available to home care providers at the time of patient transitions, as well as improves the efficiency and exchange of lab results.
Case 3: Specialty Care to Hospital to Home Care, Winchester Home Care
In partnership with the Winchester Hospital Joint Program and Excel Orthopedics and via a private health information exchange, Winchester Home Care is demonstrating how technology and education can be used to increase the number of surgical joint patients who elect home care after hospitalization. Through use of the MA HIway, the project is improving workflow for home care, the patient, the primary care and specialist physicians, reducing inpatient rehabilitation stays and improving patient outcomes.
Case 4: Merrimac Valley HIE/ER Discharge Notification, Home Health VNA
In collaboration with Lawrence General Hospital, Pentucket Medical Associates and Greater Lawrence Family Health Center, Home Health VNA has been the community leader in creating a mechanism to share information about mutual patients across their service area using the Mass HIway. The Merrimac Valley Health Information Exchange (MVIE) was launched in 2013 with the challenge of securely sharing ER discharge data to facilitate timely follow-up care and reduce further ER usage.
Under HHVNA leadership, the MVIE has faced and overcome challenges related to connecting multiple entities with different information systems and different electronic medical records, and demonstrated processes to address workflow issues related to such issues as identifying primary care physicians and home health providers. The project is now piloting discharge documents with streamlined, actionable clinical information, discharge instructions, medications and risk stratification pushed to trading partners via the HI way.
By shifting existing process away from paper-based exchanges, the MVIE is ultimately leading the way in demonstrating how a community can come together around technology to bring about measureable improvement in care quality, population health and reductions in costs.
Case 5: Discharge summaries from Acute care to Skilled Nursing Facility and Home Health in the form of a CCDA, Caretenders
Caretenders home care company, in partnership with the Milford Regional Medical Center (MRMC) and Medway County Manor is using the Mass HIway to transmit hospital discharge summaries to a skilled nursing facility close. These trading partners are establishing a process of connecting to the Mass HIway that could be replicated with other agencies who not yet using an HER.
The grant is supporting the connection of both the home health agency and the SNF by providing funding for their initial set-up on direct webmail HIE Services, as well as providing needed technical support. The project will ultimately replace highly inefficient faxed discharge summaries with electronic exchange with an aim of improving patient care. This project will include an evaluation of, and lessons about, how to proceed to connecting post-acute entities not yet using EHRs with the HI way.
Case 6: Discharge Summaries from Acute care to Home Care, Overlook Visiting Nursing Association
With its partner Harrington Hospital, Overlook Visiting Nurse Association (OVNA) is using the MA HI way to reduce the time between hospital discharge and the intake visit from an Overlook clinician.
Overlook VNA and Harrington Hospital are changing the current paper process of discharge and referral to an exchange of through the MA HIway. Discharge information from Harrington will be sent via the HIway to OVNA, where it will be scanned directly into the clinician’s tablet. OVNA completes the processes needed to schedule and plan care, significantly reducing the window of time between discharge and initial home visit.
The aims of this project are to provide the timeliest care, in the most efficient way, with as much direct information as possible, and to reduce re-hospitalization by reducing the time between discharges available to home care providers at the time of patient transitions, as well as improves the efficiency and exchange of lab results.
Award for Innovation in Health Care Cost Ctainment
To: Visiting Nurse Association of Greater Lowell
For: Health Care Affordability Begins At Home
One of the greatest challenges in home care today is bridging the gap between need and coverage. Too many of those who need assistance with chronic illness management find themselves outside Medicare or other insurer’s “skilled need” or “homebound” requirements. With a grant from the Blue Cross Blue Shield Foundation, Health Care Affordability Begins at Home targets those with chronic illness who have been identified by local physicians as at high risk for hospitalization. The program provides these patients standard home health strategies of home nursing visits, telemonitoring, self management coaching, and 24 hour nursing availability.
Additionally, the project has added a community health worker to the team to help with problem solving and teaching reinforcement. The program works in strong partnership with the local community health center and the largest local physician practice.
Award for Innovation in Patient Care
To: NVNA and Hospice of Norwell
For: Alzheimer’s Specialty Team Advanced Practice
The rapidly escalating prevalence of Alzheimer’s disease and related dementia is changing the composition of home care caseloads and challenging the competencies of the care teams. In partnership with Project ECHO-AGE at the Beth Israel Deaconess Medical Center, NVNA and Hospice staff have telecomputing access to specialty consults on behalf of their dementia care patients. In these virtual "grand rounds," the team has opportunity to pursue problem solving in an advanced clinical environment with specialists in the practice of neurology, psychiatry and social work. Patients get the benefit of an advanced specialist without leaving their homes; home health clinicians get expert advice from the most advanced specialists in the dementia field.
Honorable Mention - Patient Care
To: Home & Health Resources, Braintree
For: First Day Home
Targeted toward elder hospital patients without family or support, First Day Home is a foundation funded effort that offers a visit by a Registered Nurse – on the same day as discharge – for an assessment of home safety, medication review, pick-up and prefill, as well as adequacy of food supply. First Day Home meets a need identified through South Shore Hospital’s participation in the State Action on Avoidable Rehospitalizations (STAAR) project.
Award for Cross Continuum Collaboration
To: Baystate Health/Bay State VNA & Hospice, Springfield
For: Reducing Avoidable Readmissions with a Cross Continuum Partnership
Bay State Medical Center (a 700 bed tertiary care hospital), and its affiliated Homecare and Hospice (which serves an average of 1,000 patients per day) have been part of the STAAR initiative since its initiation in 2009. The key to their success in reducing Baystate’s 30 day heart failure readmission rate by 12% was building a broad cross continuum team that included a significant percentage of the home health agencies, skilled nursing facilities, physicians and other providers serving western MA. All members of the cross continuum team achieved consensus around, and executed, standardized patient and provider education tools. All cross continuum members participated in achieving more streamlined discharge procedures and more focused assessments of high risk patients.
The success of the teams with heart failure has led to a new goal of reducing pneumonia and COPD readmission by 25%, using the same collaborative model.
Honorable Mention – Cross Continuum Collaboration
To: Partners Health Care At Home Private Care, Waltham
For: Skilled Nursing for Low Income Frail Elders (LIFE)
For some frail elders seeking to remain in the community, avoid hospitalizations, and/or nursing home stays, it can take a care giving village. Skilled Nursing for LIFE works with clients that are in the elder services system and already identified as nursing home at risk, through a multi-disciplinary team.
Award For Excellence in Staff Development
To: HouseWorks, Newton
For: First Ever Schwartz Center Rounds for Home Care
The Schwartz Center for Compassionate Care Rounds project is dedicated to the notion that when caregivers have real facilitated conversations about the emotional and social issues that arise in their work, quality is transformed. The initial focus of Schwartz Center “Rounds” was the hospital setting. HouseWorks pioneered this concept in the home care realm, which has helped HouseWorks to improve cross function communication among teams, while creating a more uniform and outcomes driven approach to service delivery. Direct care workers report these conversations leave them feeling less isolated and more confident in their caregiving roles.
To: Nashoba Nursing Service and Hospice, Shirley
For: Visiting Volunteers program
Hospice volunteers are cross trained on communication and listening skills, issues of
aging and chronic illness and other psychosocial issues and are assigned to visit patients who are discharged from home health services to prevent relapse.
Award For Excellence in Community Outreach and Advocacy
To: GVNA Healthcare, Gardner
For: The Face of Home Care on the Street
A renewed focus on population health inherent in Dr. Don Berwick’s Triple Aim, means that for some home health agencies the “community is the client.” GVNA Healthcare’s Community Services Center is a beacon of hope in their region for the homeless, hungry, and socially isolated. As other regional programs have closed, the GVNA Healthcare’s Center has ramped up its work in substance abuse and addiction services supports, inclusive of the only regional program with a “drop in” component. With food and nutrition a serious issue for their clients and community, GVNA added a food pantry to their offerings – and they are now servicing close to 3,000 individuals and more than 500 families. With need growing every day, GVNA staff conducted their own food drive and donated more than 400 pounds of food.
Honorable Mention - Community Outreach
To: VNA of Middlesex-East, & Visiting Nurse Hospice, Wakefield
For: HomeMed Monitoring Kiosk
Installed in the Woburn and Billerica Senior Centers, their vital signs monitoring kiosks allow individuals to take and transmit vital signs to the agency for review by a nurse. Follow-up via telephone with a nurse occurs if changes in vital signs warrant attention