Fort Kent ~ Northern Maine Medical Center (NMMC) and the Aroostook Area Agency on Aging (AAAA) have partnered in order to support keeping patients living and thriving in their own homes. On January 8, 2015, representatives from AAAA, Steve Farnham, Judy Anderson and Dottie Sines, met with Cheryl Daigle, NMMC Associate Director of Nursing, to discuss ways in which both organizations could bring together existing resources from both agencies in support of patients discharged from the hospital. The partnership would pair NMMC’s courtesy home visits with an in-home safety assessment along with a supply of free meals made possible by a grant acquired by AAAA.
NMMC’s courtesy home visit program has been in place for one year and is designed to offer recently discharged patients an additional resource; the hospital sends a registered nurse to the home within three days of discharge from the hospital. With the complexity of today’s medications, the focus for the program is to assist the patient with 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.
The dialogue around the partnership began in the summer of 2014 when multiple healthcare stakeholders came to the table to explore means to assist residents of Aroostook County to live and thrive safely in their homes. AAAA, in collaboration with other area providers, was awarded a grant from the Maine Health Access Foundation (MeHAF) to help people with chronic health conditions maintain their health so they can remain living in their home and communities.
According to a November 18, 2010 white paper in the Journal of the American Geriatrics Society, post discharge interventions can work to reduce readmissions to the hospital. Most recently, the Medicare Quality Improvement Organization of Florida, under contract with CMS, conducted a pilot program that has shown success at reducing re-hospitalizations by providing free meals to elderly patients upon discharge from the hospital. Seniors enrolled in the program received one month of meals and a nurse’s visit. Results showed that the readmission rate dropped from the national average of twenty three percent to under three percent with the nurse visit and the meals. In January, AAAA and NMMC launched a partnership made possible by the MeHAF grant which provides meals to eligible patients as well as providing an in-home safety assessment. According to Steve Farnham, Executive Director of AAAA, “It seemed natural to partner some of the grant resources with NMMC’s courtesy home visits.” According to the CMS pilot, meals alone dropped readmission rates by nearly ten percent.
On January 29th, AAAA provided training to fifteen NMMC registered nurses. Nurses were introduced to AAAA’s Quick Scan program which is an assessment of the safety in the home environment. 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 may be made to AAAA who will explore available programs to assist the patient.
The unique partnership is designed to add resources in the homes of patients while NMMC nurses are already in the home to conduct the courtesy home visits. Judy Anderson, Aroostook RSVP Director and Thriving in Place Project Director said, “Research shows that over ninety percent of Mainers want to stay in their own home and community, but current resources to help them live healthy and safe are insufficient and not always effective. Our mission is to identify what is working, what needs to be improved, and how can we assist people to not only remain living at home, but thrive”. Anderson went on to describe that the Thriving in Place program will: accept referrals to County-wide coordinated community supports, emphasizing screening, self-management, education and check-in services; monitor services and follow up of patients through a centralized information system; and focus on key areas of need for medical transportation, homecare services, in-home supports, and respite/adult day care. The strategy of providing meals and a safety assessment will certainly enhance the quality of life by offering resources to individuals to keep them thriving in their own homes.
To learn more about the program visit www.aroostookaging.org.