Serving Our South County Community

South County Home Health and Community Health continue to support the well-being of residents within our community.

South County Home Health

South County Home Health is a leader in the delivery of skilled visiting nurse care, rehabilitation, mother and baby care, wound care, and other medical and non-medical services for patients who are recovering at home. As the community grows in demographics and geography, South County Home Health responds to current needs and positions itself to pivot and meet changing needs supporting our community by providing the option of quality care at home.


In FY21 South County Home Health achieved its goal of 5 Stars for Patient Experience as measured by Home Health Compare (, while maintaining 4 Stars in Quality measures.

By continuing to improve upon best practices to enhance the patient experience, our goal is to achieve a 5-Star rating in Patient Experience and Quality metrics.

Focus efforts will:

  • Implement best practices with scheduling around patients preferences.
  • Utilize Televox communication for newly referred patients to provide information that addresses patient needs prior to the start of care
  • Continue the “Give me 5” campaign, an initiative that supports patients by dedicating time during each visit to focus on the patient without distraction, providing patient centric care with a team-based approach.


Prompted by the challenges of COVID, an Interdisciplinary Team of Care model made up of nursing, physical therapy, and occupational therapy, provided the option for COVID patients to receive care in their homes. This Team of Care approach provided an alternative to the most critical patients when hospitalization or admission to a skilled nursing facility were neither ideal nor, at times, possible.


Implementing the latest technology has supported clinicians with improved connectivity, providing the team with the ability to concurrently connect with providers, and the offices for seamless communication to optimize patient care.

Clinicians now have cell phones with secure application capabilities, providing digital access to network information.

Cell phones have improved efficiencies related to scanning, scheduling, and other forms of communication via secure platforms.

South County Home Health also partnered with a new coding vendor who are experts in supporting staff to ensure the optimal capture of patient equity.


As we grow, South County Home Health seeks not only to improve the services available to our patients but also to merge into expanded rural territories. During the past year, a Registered Nurse who lives on Block Island (New Shoreham) was hired to serve the population of over 1,000 residents on Medicare who transitioned into their summer homes full time during the pandemic.

Block island infographic

Community Health

The Community Health Division provides stewardship for the community through strategic, collaborative partnerships with other organizations whose mission and vision support the health and well-being of residents within the communities we serve.

Healthy Bodies Healthy Minds (HBHM) provides programs that focus on system-level changes through a convener of community partners with individual community-based support offered through the Community Health Team and other specialized programs.

To ensure inclusivity of all communities within Washington County, South County Health provides administration and staffing for the HBHM program for its role as one of 15 Health Equity Zones in the state. HBHM is funded by the Rhode Island Department of Health, Substance Abuse & Mental Health Services Administration, The Rhode Island Foundation, and Blue Cross Blue Shield of RI.

Zero Suicide Initiative takes a population health approach to suicide prevention by implementing Zero Suicide within the region’s eight major healthcare organizations, including South County Health. An important part of this effort is having an adequately trained workforce and universally screening patients for depression and suicidality.

  • To date, 661 of 1,562 (42%) of South County Health’s staff have been trained in Question, Persuade, Refer (QPR) suicide prevention training.
  • HBHM conducted 63 community QPR trainings, certifying 476 participants as QPR Gatekeepers. QPR trainings have been provided to approximately 20 community organizations.
  • A universal Patient Health Questionnaire (PHQ) was implemented for patients seen in the Emergency Department and inpatient setting and will phase in to outpatient facilities and home health. To date, 24,063 PHQ-9 screenings and 8,181 C-SSRS screenings have been conducted to identify patients at risk of suicide.

Mental Health First Aid (MHFA) Mental health awareness and training are key to demystifying mental health and getting people the help they need. MHFA is designed for that purpose.

  • HBHM expanded MHFA course offerings to include youth, as well as modules specific to public safety, fire/EMS, veterans, higher education, and older adults.
  • All eight Washington County police departments and the University of Rhode Island have Crisis Intervention Team (CIT) trained officers. CIT partners with local law enforcement to decriminalize mental illness and keep officers and those with mental illness safe. Four of the county’s police departments achieved the gold standard of having 20% of their force CIT certified. Across Washington County, 49 officers are CIT certified.

The Community Health Team, First Connections and Healthy Families America are patient- and family-centered home visiting programs working to improve the health and well-being of the residents in Washington and Kent counties through health coaching, health literacy education, care coordination, linkages to community resources, and behavioral health counseling.


  • Maternal and Child Health
  • Behavioral Health
  • Senior Health and Support

Reduce substance use disorder

Funded by State Opioid Response money, community health workers and behavioral health care managers from the Community Health Team partnered with South County Home Health First Connections Nurses to provide free, voluntary, confidential home visits to pregnant women, new mothers with substance use disorder and their babies. The team provides safe sleep and early childhood education, developmental screenings, and connections with appropriate healthcare services and community resources to support both mothers and substance-exposed newborns.

Behavioral Health

In Washington County, the death rate due to mental health and behavioral disorders is higher than the national average. During the COVID pandemic, factors such as social isolation, fear, and in some cases loss of employment exacerbated the incidence of substance abuse and the detrimental outcomes — personal and social — that result. In an effort to address this critical need in the community, the Community Health Division supported a number of programs designed to identify and intervene when individuals are at risk.

Senior Health

To address key elements that impact health and social needs of seniors:

  • Deployed telehealth services to meet the needs of home-bound patients during the pandemic.
  • Provided behavioral health follow-up after emergency room visits to ensure individuals at risk were connected to services and received support until appropriate treatment services were in place.
  • Screened 345 individuals for social determinants of health and behavioral health needs from July 2020 through June 2021, doubling the previous year’s screenings and provided services to over 622 individuals during this same time with 5,736 phone, telehealth, and home visits.
  • Initiated a pilot disease management collaboration with Wood River Health Services supported by the Rhode Island Department of Health to provide disease-specific health coaching.

Annual Report 2021

Next up:

FY2021 Key Hospital Statistics

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