Tuesday, 25 October 2016 04:04

Good Health in the Community

Written by Michelle Hafner, RN, BSN and Robert Fortini, PNP

Bon Secours Home Care, the Instructional Visiting Nurse Association (IVNA), and the Bon Secours Virginia Hospital System and Bon Secours Medical Group have collaborated to develop an integrated approach to providing healthcare support within the community and at home, leading to decreased hospitalizations and increased preventative care delivery. The program focuses on supporting two at-risk populations: the patient discharging from the hospital who is at high risk for re-hospitalization, and the population in the community at risk for communicable diseases.

The first initiative, the Hospital to Home (H2H) program, focuses on those patients who have been hospitalized but do not meet the criteria for home care even though they present as having high risk for re-hospitalization. Team members from Bon Secours Acute Care, Ambulatory Care, and Home Care collaborated to develop the H2H program, identifying gaps in care and working to close those gaps for this population. 

The second initiative is the IVNA immunization program. IVNA provides immunizations at on-site and off-site clinics, and for homebound home care patients. A portion of the proceeds from these clinics supports charity home care within the community.

Overview of the H2H Program

Under this new program, consider the following example: prior to discharge from the hospital, the patient is identified as being at high risk for re-hospitalization. Upon screening for a home care referral, the patient fails to meet the criteria for home care. A referral is then made from the hospital for a home care visit as an extension of the hospital discharge process. The patient is seen at home for a one-time, face-to-face visit with a nurse. This nursing intervention includes a patient assessment, medication reconciliation, psycho-social assessment, and an evaluation of available support systems, and it provides the patient with education on medications, the disease process, diet, and any other areas that impact daily life at home. The nurse also confirms that the patient has a post-hospitalization appointment with their physician, and if not, he or she assists the patient in making that appointment. The nurse then provides the patient’s physician with a verbal and written report detailing areas of concern and emphasizing needed follow-up based on the face-to-face visit.

The Hospital to Home program, launched in 2014, has been extremely successful in reducing readmissions, resulting in a current average readmission rate of 1-2 percent. Data is collected on several factors that impact patient success, including the percentage of patients with a follow-up physician appointment, percentage of chronic heart failure (CHF) patients with a scale in the home, percentage of medication discrepancies identified through in-home assessment, and the readmission rate of patients in the program. 

Description of IVNA Immunization Program

The Instructional Visiting Nurse Association (IVNA) is an agency that provides immunizations. Projections show that in 2016, IVNA will administer approximately 27,000 flu shots at on- or off-site clinics or at various corporations, churches, community events, senior citizen communities, or in the homes of homebound patients in the Richmond, Va. area. IVNA also provides vaccines for pneumonia and other communicable diseases. A portion of the proceeds from this program is designated to support uninsured and underinsured patients in need of home care. IVNA has been a vital force in improving the wellness of the community as well as in the prevention of unneeded hospitalizations. 


The goal of these programs is to have a positive impact on community wellness, to improve patient success in managing healthcare at home, to decrease hospitalizations and readmissions, and to close gaps in the transitions of healthcare. Team members working in integrated healthcare across the continuum, representing the Hospital to Home program and the IVNA Immunization Program, certainly impact the health of the community they serve. 

About the Authors

Michelle Hafner, RN, BSN is a graduate of The University of Maryland School of Nursing and has been a nurse for 40 years, with a focus on home healthcare for most of her nursing career. She has been with Bon Secours for the past seven years. Michelle has been a champion for clinical transformation and closing the gaps in the transitions of care. While at Bon Secours, working in tandem with the inpatient facilities, ambulatory care, palliative care, hospice, and home care, she has developed the H2H program, standardized patient education programs utilized across the continuum, helped launch the home care-to-hospice bridge program, and achieved pharmacist integration with medication reconciliation.   

Robert Fortini, PNP, VP and chief clinical officer for Bon Secours Virginia Medical Group Home Health and Hospice, is responsible for facilitating provider adoption of electronic medical records (EMRs), plus coordinating clinical transformation and facilitating advances in population health initiatives. Robert has extensive experience in operations and clinical policy development and in workflow reengineering and CQI in ambulatory care. He recently advanced Bon Secours’ efforts in “Good Help for Life” by leading efforts in advance care planning and behavioral health integration into primary care, promoted access via expansion into the retail clinic and telehealth arenas, and developed a workforce equal to the task. 

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Last modified on Wednesday, 26 October 2016 00:25