In May of 2012 Mercy was awarded a $63,000 grant from Harvard Pilgrim Healthcare Foundation to develop a Specialty Care Medical Home at Mercy Cardiology. Building on Mercy’s vision for person-centered care, our Specialty Care Medical Home will improve patient health outcomes, patient access, and patient satisfaction, by providing needed care at the right time, at the right location and at the appropriate cost. Our focus is on person-centric care coordination and the identification of avoidable complications by addressing symptoms early and helping our patients to better manage their disease.
To lead this charge Mercy Cardiology has hired Lisa Casher, RN, BS, MEd, as our Patient Care Navigator. Lisa has been a nurse on 5B for many years. She will continue in both roles, and is very excited to work closely with our patients with heart failure to help them better understand their disease and manage their care. Lisa will be working closely with the VNA and their home care and home remote monitoring systems. These home monitors are able to track high-risk heart failure patients and send regular reports to Lisa and the VNA Home Health Nurses. Together, and linked through our integrated EMR, the program will manage protocols for diuretics, labs and teaching, based on individualized patient triggers. Community-based Registered Nurses will provide rapid in-home physical assessments if indicated to treat the patient and/or determine the best location for further care. Through greater communication and coordination across the continuum of care, we expect to see a 5 % reduction in both ED visits and in-patient admissions among the patients enrolled in the program as heart failure is one of the highest readmission diagnoses. Our hope is to develop a model that can be replicated across other specialty practices.
