The situation: HealthAlliance-Clinton Hospital acquired the Home Health operation in 2009. It was a traditional free-standing Visiting Nurses Association (VNA) organization delivering in-home nursing, rehabilitation, personal care and hospice services in northern Worcester County. The VNA team was not integrated into the culture of the hospital. Instead, the team worked in a large space off campus, isolated physically and the staff felt largely forgotten.

Beginning in 2013, a new leadership team was put in place with the aim of improving the quality of care offered by HealthAlliance Home Health & Hospice to allow patients to remain healthy and at home. This meant expanding the scope and methodology of services provided and required fresh thinking by leadership and front-line staff alike.

Christine: When I began back in 2012, there were many challenges within the organization for Home Health & Hospice. There were operational inefficiencies, an electronical medical records system that was not properly utilized, and staffing challenges to name a few. Our financial picture also needed improvement.

My first task was to earn the trust of the staff. As a new leader with a different style, the staff needed to see that I would live up to my word and follow through on what I said I was going to do. My style is very much a team approach. I want to empower the staff to make good decisions. Not necessarily the right decisions, but it’s how we learn … to feel comfortable to speak up, to not feel as though anyone is going to be blamed. We encouraged everyone, the administrative staff in the office as well as the staff in the field to speak up if they have an issue that needs to be brought forward. And the leadership team has to know how to welcome that.

Jen: It is a very unique experience for our field nurses. It’s unlike any inpatient setting or outpatient setting. The population that HealthAlliance Home Health & Hospice serves is a very large population. We cover about 30 plus towns. The nurses are pretty much working on their own, so there is a lot of autonomy out there. We don’t have doctors that are immediately available for questions. We don’t have other nurses that are in the homes with us, so it can be very stressful. We call it managed chaos, because every day you don’t know what you are going to get, or who you are going to be visiting, or what conditions will be like. We are out in snowstorms, rainstorms, high heat, no electricity. So, any time that there is anything going on in the community, we are still out there on the roads, taking care of the patients.

In the beginning patient satisfaction scores weren’t as good as we wanted them to be. And we knew it was because there were changes that needed to happen, because if you have an unhappy, stressed field staff, we knew that our patients felt it. So, we spent time -- we involved team members in meetings to understand their issues, we implemented group management of cases so that we can call each other, support each other and changed how we worked as a unit. When we did that, our field staff felt happier and our patient satisfaction scores shot up.

Diane: Home health and hospice is unique. There are so many disciplines that must interact with one another. It does have its challenges, but the team pulls together. It’s all about the patient and we are so patient-focused – kind of doing whatever it takes and then some to get the job accomplished while making sure our patients are happy, safe and that there is a good outcome. For example, I have been managing the telehealth program here at Home Health & Hospice for five years now. This innovation came from the belief that with telehealth, we could intervene early on. And early intervention has kept patients out of the emergency room and out of the hospital.

I work closely with the nurses, with the rehab team, with the physicians. The nurses go into a patient’s home maybe two to three times a week; we oversee vital signs, their signs and symptoms. We call most of our patients every day. It is a 365-day operation. Holidays, weekends -- I mean, we are there -- we feel like we’re their lifeline. “I don’t feel well today; can you send a nurse out to see me?” The nurses love that communication from me and from the other telehealth nurses, because we’re giving them up-to-date information, as it’s happening. Telehealth has made an enormous difference in the care delivery that we foster here.

Ginger: As the case manager at HealthAlliance-Clinton Hospital, I make sure that patients move smoothly between various settings of care. When I first came here, everybody kind of worked in silos. We made referrals to Home Health but we didn’t really know them. We didn’t really know what they did on their end. When Chris Dixon took over she reached out to get our two departments together. We started meeting, and we talked about barriers and what’s going on in their world, and what goes on in the hospital world, how could we better work together? And so that relationship just grew and grew, and now we meet every month, and continue that relationship to make sure patients have everything that they need when they’re going home, if they are going home with Home Health & Hospice.

Valerie: I am the clinical nurse liaison for HealthAlliance Home Health & Hospice. My responsibility at the hospital is to work with the case managers when they have a patient that is ready to go home. If the patient will need services at home, I connect with the case managers and begin the process of setting up home services for patients.

I think it makes the transition home much smoother. If there is somebody in the hospital that can meet with the patient and the family before they leave the hospital, so that they know what to expect from us once they get home. It kind of takes away the unknowns and makes them a little less fearful of what’s going to happen.

Deb: I’m a home health nurse. This is what I always wanted to be, to work with people in the home. I think it’s very important for patients to be at home. But they are a lot sicker than they have ever been at home so it can be very scary. They and their families need the support I provide. Sometimes it’s emotional support that I must provide. Sometimes I help them connect with their doctor. Whatever they need, I help them with it. Of course, all the while I’m providing the nursing care they need, vital signs and all. But I kind of build a trust with them too so they feel safe with me.

I also rely a lot on the teams back in our office to help me work efficiently. The schedulers, intake team and the supervisors all make my job a lot easier. I know I can rely on them to respond quickly with the information I need if I can’t reach a patient or with any problem I’m having on the road.

Christine: There’s so much to our story – innovations like pioneering IV Lasix in the home, lowering readmission rates by 20 percent, being recognized among the best home health operations nationwide for patient and family satisfaction.

It’s a great honor to take care of patients in their home and I feel as though the organization always focuses on providing high quality of care. And with that being the top priority, everything else falls into place. I feel proud of the team that we have, proud of the leadership, proud of the administrative staff and proud of the hard-working clinicians, each one of whom goes out to patients’ homes every day in all kinds of settings, all kinds of communities.

Stay tuned for more features about teams who innovate in the weeks ahead. Know a team who deserves Everyone, Everyday recognition? Nominate them to be featured!