SERVING OUR SOUTH COUNTY COMMUNITY AND BEYOND
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.
In FY2022, 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:
- Optimizing best practices with scheduling around patient’s preferences.
- In home leadership rounding to support newly admitted patients and follow discharge calls to ensure smooth transition back to community support.
- Roll out of OASIS E CMS metrics to align documentation through transition of care.
South County Health has supported clients throughout the pandemic, providing financial assistance, education, social and emotional support, among other items. The following is a list of services provided by the SCH Community Health Team, First Connections, and Healthy Families America:
- Supplied grocery gift cards and Be Safe bags with cleaning supplies, masks, gloves, sanitizer, hygiene items, paper goods, thermometer, and food items.
- Helped home-bound patients and COVID quarantined families to arrange pick-up or delivery services for prescriptions.
- Provided pick-up and delivery services from the local food bank for home-bound patients.
- Provided ongoing social and emotional support to patients and families socially isolated during the pandemic, including regular check-in phone calls.
- Supported vaccination education and clinics.
- Supported issues related to housing, evictions, and other moratoriums, including partnership with the Medical Legal Partnership of Boston (MLPB) for legal counsel.
- Offered 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.
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 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.
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.
Washington County Zero Suicide Program 2022 Highlights:
To date, 428 of South County Health’s staff have been trained in Question, Persuade, Refer (QPR) suicide prevention training and all new employees go through training as part of their orientation.
HBHM conducted several in-person and digital community QPR trainings, certifying 814 participants as QPR Gatekeepers, a 71% increase in participants over FY21. QPR trainings have been provided to approximately 25 community organizations.
A universal Patient Health Questionnaire (PHQ) was implemented for patients seen in the Emergency Department with South County Hospital screening all ED patients 25 and up. In FY22, a total of 68,155 PHQ and C-SSRS screenings have been conducted to identify patients at risk of suicide, a 111% increase in screenings over FY21.
Middle-aged men remain the highest risk for suicide in Washington County. Because many men at risk are not engaged with healthcare providers to undergo systematic screening, we have worked to identify them through a continued investment in the Man Therapy program, which uses humor to get men to pay attention. In FY22, 1,434 new users from Washington County visited the Man Therapy website.
FOOD IS MEDICINE
In the Fall of 2022, South County Health’s Food and Nutrition Department partnered with Johnnycake Center For Hope to help kick off their culinary nutrition program, 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.