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Local Voices

NEWTON-WELLESLEY HOSPITAL AND NEWTON AT HOME COLLABORATE TO PREVENT HOSPITAL READMISSIONS

It was almost one year ago when Newton-Wellesley Hospital Community Care Manager Connie Schrader first called Newton at Home Executive Director Maureen Grannan for assistance with a patient- a 64 year old widow living alone in subsidized housing, who was just discharged after an emergency room visit for significant back pain and congestive heart failure. She had no local relatives or support systems, and was unable to drive. Pretty routine call- except this time it happened to be during the aftermath of the Boston Marathon bombing. Several communities were in lockdown and residents were told not to leave their homes.  

“Newton and Watertown were in lockdown, but I knew this woman needed help,“ said Grannan.  “When the lockdown ended, I arrived at her house. All of the shades were down, windows were shut tight, and the television volume was turned all the way up, shouting the news about the manhunt for the alleged Boston Marathon bombers.”  Grannan talked with the woman for a little while, performed a safety check, arranged to have her prescriptions picked up from the pharmacy, and groceries delivered to her home. “The woman lived a quarter of a mile from all the drama. She was so scared.”

Since then, Grannan’s volunteers have helped numerous Newton residents live safely in their homes to avoid re-hospitalization. Through an innovative community alliance between Newton at Home (NAH) and Newton-Wellesley Hospital, patients over the age of 60 who reside in Newton may be eligible to receive services from NAH volunteers to provide the support they need to ensure a safe transition to home. Newton-Wellesley covers the cost for the first 30 days of services, at which time a patient may voluntarily extend the agreement with Newton at Home directly. If an eligible patient cannot afford the cost of extending the services, Newton-Wellesley can offer some financial assistance.

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“We hope that the services we are offering to some of our most vulnerable patients will promote a smooth transition back to home, while encouraging safety and security for managing as independently as possible in their homes and ultimately reducing rehospitalizations,” said Monica Ferraro, Manager, Care Coordination, Newton-Wellesley Hospital. 

Prior to being discharged from the Hospital, eligible patients are identified by a Registered Nurse Case Manager or Licensed Clinical Social Worker and informed about Newton at Home community services.  If the patient agrees with accepting the short term services, a NAH volunteer is assigned and meets with the patient to assess his/her needs and determine which services would be most appropriate, i.e.  home safety checks, transportation home from hospital; prescription pick-up; transportation to follow-up appointments; errands; grocery shopping, etc. In addition, daily check-in phone calls or visits are made to the patient’s home by Newton at Home volunteers. Often, NAH services will include emotional support as members deal with the difficult challenges of illness or infirmity.   At the end of the service agreement sponsored by NWH, Newton-Wellesley will receive feedback about the utilization of services and assess its impact on quality, patient satisfaction and hospital readmission rates.

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“Patients who have limited social support and lack the financial resources to manage everything that keeps them independent tend to frequently visit the Emergency Department,” added Ferraro. “Our goal is to help vulnerable residents in the community recover at home quickly, remain out of the hospital and resume independence as soon as possible.”

Newton at Home is a non-profit membership organization designed to help Newton residents 60 years of age and older live active, more independent and connected lives in their own homes and apartments through access to a broad variety of social programs and practical services.  For more information about Newton at Home, call 617-795-2560, email info@newtonathome.org or visit www.newtonathome.org.

Newton-Wellesley Hospital is a full system member of Partners HealthCare System, Inc. (PHCS), a nonprofit organization that includes acute care hospitals Massachusetts General Hospital, Brigham and Women's/Faulkner Hospitals, The North Shore Medical Center, and specialty hospitals McLean Hospital and Spaulding Rehabilitation Hospital, as well as Dana-Farber/Partners CancerCare, and the community-based doctors and hospitals of Partners Community HealthCare, Inc.

Newton-Wellesley Hospital provides a wide range of services, including medical, surgical, obstetrical, orthopaedic, neonatal, pediatric and psychiatric care. Newton-Wellesley has been serving its community for over a century. The medical staff of the Hospital includes nearly 1,000 physicians practicing a full range of specialties. NWH is a major teaching hospital for Tufts University School of Medicine and also has established post-graduate training programs for Harvard Medical School residents.

To make an appointment with a physician or for more information about Newton-Wellesley Hospital’s services, specialties, free health screenings, lectures and other events, contact CareFinder at 617.243.6566 or visit www.nwh.org

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