SERVING OUR SOUTH COUNTY COMMUNITY AND BEYOND
Home Health
South County Home Health is a leader in the delivery of skilled visiting nurse care, rehabilitation, 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.
We are proud to offer specialty services such as Big and Loud, Certified Diabetic Educators, Certified Wound Nurse, as well as staff certified in Lymphedema therapy and Vestibular therapy.
PATIENT EXPERIENCE
In FY2023, South County Home Health achieved its goal of 4 Stars for Patient Experience as measured by Home Health Compare (Medicare.gov).
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:
- Optimize best practices with scheduling around patient preferences.
- Support newly admitted patients with in-home leadership rounding and follow-up on discharge calls to ensure smooth transition back to community support.
- Encourage all Home Health staff to complete Field Staff OASIS-E certifications.
ADDRESSING SOCIAL DETERMINANTS OF HEALTH
South County Health has supported clients with Social Determinants of Health (SDOH), providing financial assistance, education, social and emotional support, among other items. The following is a list of services provided by the South County Home Health community health worker:
- Supply grocery gift cards and Be Safe bags with cleaning supplies, masks, gloves, sanitizer, hygiene items, paper goods, thermometer, and food items.
- Help home-bound patients and families to arrange pick-up or delivery services for prescriptions.
- Provide pick-up and delivery services from the local food bank for home-bound patients.
- Provide ongoing social and emotional support to patients and families socially isolated during the pandemic, including regular check-in phone calls.
- Support vaccination education and clinics.
- Support issues related to housing, evictions, and other moratoriums, including partnership with the Medical Legal Partnership of Boston (MLPB) for legal counsel.
- Offer a borrowing service for iPads and WiFi hotspots to enable patients to connect with friends and family, schedule medical appointments, and/or attend partial day programs.
Community Healthcare
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
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 provided administration and staffing for the HBHM program for its role as one of 15 Health Equity Zones (HEZ) 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.
Washington County 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.
From January 1, 2019 to September 29, 2023 a total of 36 organizations including South County Health trained staff through face-to-face and online Question/Persuade/Refer (QPR) training modalities. Across Washington County, a total of 2,812 health care workers were QPR trained. South County Health is also one of seven health care organizations in Washington County that conducts universal screening of all emergency department patients ages 25 and up using the Patient Health Questionnaire (PHQ) 2, PHQ 9 and the Columbia Suicide Severity Rating Scale (C-SSRS). A total of 258,107 PHQ and C-SRRS screens were conducted from 2020-2023.
Washington County Zero Suicide Program 2023 Reports:
Download WCZSP Final Report ›
Download MTWC Final Report ›
Behavioral Health in Rhode Island
Washington County is a designated mental health shortage area due to an inadequate number of providers and inpatient beds.
The Mental Health Association of Rhode Island recognizes multiple reasons for the current state of the mental health care landscape in Rhode Island. Lack of resources, however, is cited by 67% of providers as a reason for not being able to accommodate new patients into their already full caseloads.
Additionally, the pandemic has had profound and far-reaching effects on Americans’ mental health. Depression among adults in the United States tripled in early 2020 — jumping from 8.5% before the pandemic to a staggering 27.8%. Findings indicate this trend is actually worsening, affecting one in every three American adults.
Mental health challenges are impacting children too; with increasing proportions of mental health-related visits for children aged 5 to 11 and aged 12 to 17.
Substance abuse and overdose deaths are also spiking. More Rhode Islanders died of accidental drug overdoses in 2021 than any other year on record, according to the Rhode Island Department of Health. Short staffing and lack of available beds has led to long wait times and delayed services.
Community Approach to Behavioral Health Care
South County Health has been actively working within Washington County on improved care for behavioral health patients for many years, collaborating with local partners, people with lived experiences of behavioral health issues, and state and local officials. While there is a crisis at hand, we are working toward sustainable improvements including investments in:
- Significant environmental upgrades to Emergency Department Behavioral Holding Unit (ED-B)
- Psychiatry services
- Crisis Intervention Training
- Suicide Prevention Training
- Behavioral Health Trained Nurses and Ancillary support
- Care Plans and Clinical Pathways
- Utilization of Newest Medication Regimes
- Community Health Workers
- Peer Support Workers
- Leveraging Patients with Lived Experiences
- Growth in Social Work Services
- Community Care Team
- Paramedicine
- Collaboration with Local and State Partners
Rhode to Equity
One such partnership within Washington County is through Rhode to Equity (R2E), a RIDOH two-year grant with funding under the Washington County Health Equity Zone (HEZ) to support community-based initiatives providing equity and access to care all of which align with the Community Health Needs Assessment initiatives.
The grant allowed SCH to add two full-time community health workers to support patients with multiple emergency room visits and intervene when identifying gaps in Social Determinates of Health (SDOH) such as food insecurity, housing instability, transportation, safety, or financial concerns. The program is in partnership with Thundermist, who also added one full-time community health worker to connect patients to long-term access to behavioral health care in the community with their well-established psychiatric providers and programs.
SCH invested in a behavioral health-friendly unit adjacent to the emergency department, an advanced practice provider position for early initiation of medication management, and earlier access to treatment. All staff are trained in suicide prevention and initiation of de-escalation training. Local EMS provides a Paramedicine Program that can complete home visits for patients as another layer of support post-hospitalization.
SCH and Thundermist launched a Community Care Team in October 2023, convening local municipal and community partners to review community members with the highest need to consider options for wrap-around services stabilizing and improving long-term issues person by person.
Goals
- Reducing avoidable visits to the ED for Behavioral Health reasons
- Reducing total time in the ED for Behavioral Health concerns
- Starting as early as possible - treatment in the ED
- Improving Transitions of Care among patients who visit the ED for Behavioral Health, including connections and follow up through Primary Care and Behavioral Health providers
- Improving overall Patient Experience for Behavioral Health patients
R2E Data
Overall, goal was achieved of reducing High Utilization patients & visits to the ED:
- 649 interventions for 277 individuals
- For 7 individuals tracked, this meant a total of 44 fewer visits as compared to the prior year.
- R2E supported systemic improvements, including investments in a behavioral health friendly unit, and improved basic needs such as better meal options and more activities.
FOOD IS MEDICINE
In FY2023, South County Health’s Food and Nutrition Department continued to partner with Johnnycake Center For Hope, helping to provide basic nutrition education to community members. Through the partnership, South County Health led the Food is Medicine program, a ten-week cooking and health education series for people living with, or at risk of, diabetes. Culinary nutrition education lessons were provided, featuring cooking demonstrations and a focus on how those living with diabetes can better manage their condition through diet.
Testimonials
Every year, thousands of patients pass through our doors with stories of struggle, strength, hope, and perseverance. Many will form special and lasting bonds with their doctors, nurses, social workers, and other staff.
Below are a few different patients stories and testimonials from this past year that came through our Expressions of Gratitude program. Gratitude comes in many forms. At South County Health, we invite patients, visitors, and staff to share expressions of gratitude for the care provided whether that is through sharing their story, with a simple thank you, through a nomination, or with a gift of support.
