Offered to members of the Tufts Medicare Preferred program, the 360 Degree Concierge Program proactively manages care for its highest risk patients. This insurance-based program allows participants to receive managed care at every health touch point. Nurse Practitioners and RNs review a high-risk patient’s case prior to a primary care visit so that any pressing medical issues are brought to light. The group also assesses risks for falling and drug interactions.

Some patients on anticoagulation medication may require frequent monitoring of their Coumadin levels. This helps ensure that high-risk cardiovascular patients take their medications at specified times and do not miss vital doses. Patients can visit any Signature Healthcare facility to receive an INR test or have the test performed at home by a
visiting nurse. All results are fed into a central database and reviewed by the Nurse Manager for patients on anticoagulation medication. She immediately contacts the patient’s cardiologist when results seem unsafe or concerning.

This system-wide interventional healthcare-screening program relies on an on-site case manager/liaison at Signature Healthcare to coordinate care between at-risk behavioral health patients and crisis intervention programs within the community. After internal efficiency reviews, we found that many behavioral health patients were spending too much time in the ED, waiting to be assessed. This program has significantly enhanced the timeliness of care for patients with behavioral health issues and improved mental health outcomes.

High-risk, Congestive Heart Failure (CHF) patients often require additional care management while at home or in rehab. This program coordinates all at home interventions performed by Registered Nurse Practitioners and nursing students. Also, the CHF Program promotes a “teach-back” approach to patient education so that CHF patients are empowered to recognize symptoms and stay one step ahead of their illness.

At Signature Healthcare, we offer diabetic and pre-diabetic patients access to a host of integrated services including consultations with a nutritionist and a direct line to the team at Signature Healthcare’s
Weight and Wellness Center. In addition, our Diabetic Roster meetings focus on identifying pre-diabetic patients in the community to facilitate referrals to primary care physicians and endocrinology specialists.

This chronic disease management program strives to reduce hospital admissions for COPD and Asthma patients. These serious and widely prevalent diseases are aggressive yet treatable in their early stages with the right system of outpatient and hospital-based support. Our COPD/Asthma team works together to lower risks, improve diagnoses, maintain aggressive monitoring and oversight (and intervene early if necessary). The result? Higher quality of life for patients, reduced hospitalizations and readmissions, and lower costs.

In the ambulatory setting, or prior to a patient being discharged from the hospital, a fall-risk assessment is given to the patient — highlighting potential risks for falling both at home and out in the community. Should the patient prove to be at high fall risk, a series of preventive recommendations are made, and in some cases, interventional resources are provided (such as physical therapy). Also, when needed, a visiting nurse will do an at-home assessment to identify safety risks or concerns and intervene when appropriate – i.e. removing scatter rugs or other objects that could lead to a fall.

The Homeward Bound program was developed for patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). The program provides each patient with the resources and education needed to manage their disease process successfully. The program aims to reduce Emergency Department visits and lower the hospital readmission rate for patients in these high-risk categories. Within the Homeward Bound program, the Brockton Hospital School of Nursing assists patients with COPD, and the Congestive Heart Failure Team assists patients with CHF.

To achieve the goal of reducing readmission rates, patients enrolled in the Homeward Bound program are provided with weekly home visits or telehealth phone calls from a Registered Nurse or nursing students and faculty from the Brockton Hospital School of Nursing. Depending on their diagnosis of COPD or CHF, the Homeward Bound program provides patients with applicable telehealth monitoring devices, including an iPad, pulse oximeter, blood pressure cuff, or a scale. Using these Bluetooth devices, the Homeward Bound care team can track and monitor patient vitals remotely. The devices also allow each patient to answer a set of questions about their current status, any changes in symptoms, their daily limitations, among other important data points. These submissions provide the Registered Nurse with information about the patient's overall health status each day. By analyzing this data, the Registered Nurse is promptly alerted to any warning signs of a patient's potential deterioration and can help arrange early treatment and intervention.

The Homeward Bound care team provides each patient with personalized education to successfully manage COPD or CHF. The care team reviews and offers education related to the patient's medications and encourages them to adhere to their treatment plan. A weekly check-in from the care team provides emotional support while also allowing each patient to ask questions in the comfort of their own home.

Administered primarily through Signature Healthcare’s Bridgewater office, this program serves as an umbrella for a series of individual Medical Home Programs, including:
• PHQ-9 Depression Screening
• COPD Screening
• Pain Management Screening
• Pre-Diabetes Screening

This technology-driven program is designed to provide a clear picture of what happens to a patient’s medication lists and compliance at various points of care, such as post-discharge or between primary care visits. Using iPads and FaceTime, our Managed Care Pharmacist connects with the patient or their caregiver and conducts a medication review. This provides patients with a greater understanding of proper medication use, correct dosing, labeling and timing.

Medication non-compliance is one of the leading causes of hospital readmissions and/or complications post-discharge. Our “Meds to Beds” prescription delivery program was designed to make it easier for inpatients to get access to the meds they need while also improving compliance and lowering costs. Medications are delivered to patients in their hospital rooms prior to discharge. Also, at the time of delivery, a clinician explains prescription protocols and answers any questions the patient may have. The “Meds to Beds” program is particularly helpful in improving compliance in cases where there’s a language barrier.

This direct, connected care effort between Signature Healthcare’s Emergency Department and physicians in local nursing homes is designed to create more seamless lines of communication. From behavioral or pain management issues to general medical services including urgent care, this initiative helps ensure that patients get the care they need, where they need it.

Having an interdisciplinary team work with patients across the continuum of care leads to better health outcomes, lower costs and reduced risk of emergency and inpatient hospital readmissions. Our Complex Care Program brings together a care manager, community health worker, licensed social worker, palliative care coordinator and
nurse practitioner. Together, the team develops individual care plans for the highest risk patients and provides care coordination, education on self-care resources and access to community-based services. Patients are monitored for 30-60 days post-discharge.