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D-H Concord & Concord Regional VNA Pilot

December 03, 2012
Concord, NH

Dartmouth-Hitchcock Concord and Concord Regional Visiting Nurse Association (CRVNA) have partnered together in an effort to improve the overall health of patients while lowering the overall cost of care. Plain and simple, their goal is to keep patients as healthy as possible by helping them manage their diseases or conditions at home and in the office instead of at the hospital.

How are they doing this? The answer is twofold: first, by providing patients with the support they need upon discharge from the hospital through in-home medicine reconciliation; and second, through an integration of technology that has improved care coordination and communication among the entire care team.

The program is designed to identify high-risk patients (those who have a high probability of re-entering the hospital within 30 days of discharge) immediately upon admission to the hospital. By sharing access to each organization's electronic medical record, these patients are identified and enrolled in the program while hospitalized. This allows both the Dartmouth-Hitchcock medical home team and the VNA to be involved in the patient's care from the beginning, providing them with a direct understanding of the patient's condition and needs while in the hospital as opposed to after the patient is discharged.

Once the patient is discharged from the hospital, a CRVNA Home Health Nursing Coordinator visits the patient within 24 hours to identify any barriers to care and to review their medications to ensure they understand what they are supposed to be taking and at what dose.

"Patients are confused about what medications they are supposed to be taking. It's the biggest mistake I see," said Senada Alic, CRVNA Home Health Nursing Coordinator.

The role of the Nurse Coordinator is to not only understand the health needs of a patient, but to also be sure that there aren't any other elements that could prevent a patient from recovering, such as a lack of food, transportation, or family support. According to Pushkala Murali, Associate Medical Director and Primary Care physician, having the same visiting nurse seeing the patient helps with coordination of care, as the nurse understands the emotional, physical, and socioeconomic conditions of that patient.

What makes this program unique is the ability for both organizations' electronic medical records to be integrated. According to members of the project team, this improvement in communication makes the patient's transition from the hospital to home much smoother, as changes to a patient's health are entered electronically, allowing the patient's entire medical home team to be alerted to any changes to the patient's condition immediately.

The project has grown to include hospitalized high-risk patients of 13 Dartmouth-Hitchcock Concord health care providers, and has been effective in decreasing hospital readmissions through improving patients' ability to take medications.

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