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NORWELL VNA STAFF PUBLISHED IN APRIL ISSUE OF
HOME HEALTHCARE NURSE
Home Care Today: Showcasing Interdisciplinary Management
April 17, 2007 (NORWELL, MA) – An article written by members of the Norwell Visiting Nurse
Association’s Interdisciplinary Team was recently published in the April issue of Home HealthCare Nurse. The article
entitled “Home Care Today: Showcasing Interdisciplinary Management in Home Care,” was authored by Jackie Crossen-Sills,
PT, PhD with input from Registered Nurses Jennifer Rosebach and Linda Simms, Occupational Therapist Wilma Bilton, and
Physical Therapist Michelle Bickford.
According to the authors, the primary goal of the article was to emphasize the importance of communication, teamwork
and coordination in successful discharge planning. The article also highlights the courage, creativity and flexibility
required of a home care team who are committed to providing quality care to allow a patient to remain in their home after
a hospitalization.
Home healthcare has changed dramatically over the past 10 years, a change fueled by the increasing level of care
required of patients in the home, as well as the desires of patients to remain at home safely. With more patients using
home healthcare services, it has become imperative that home healthcare agencies manage the discharge process by
coordinating patients, families, doctors and other healthcare providers in order to provide organized, safe discharge
practices.
The Norwell VNA presented its comprehensive discharge process at “Grand Rounds,” a learning exchange between
University of Massachusetts – Boston nursing students and Norwell VNA staff. At the event, Bilton, Bickford, Rosebach and
Simms presented the case study featuring a patient with complex medical conditions and a lengthy medical history that
included a stroke, heart failure, diabetes, and heart disease. The Norwell VNA Interdisciplinary Team highlighted for
attendees the patient discharge process and the steps involved in coordinating the hospital discharge to home care with
patient, family members, doctors and the Norwell VNA.
The team presented four discharge scenarios to the patient’s family members for their consideration. After hearing
the options, the family decided to modify the patient’s home by adding equipment to assist in safety and hire caregivers
to supplement the care provided by the Norwell VNA. In addition the patient could transition safely to home and receive
extensive skilled nursing care, physical therapy and occupational therapy to improve independence and well-being.
“By putting two or three new strategies into practice, you can make a huge difference,” said Dr. Crossen-Sills.
“A ‘one-size-fits-all’ approach doesn’t apply in today’s home care industry. The key is to understand the uniqueness
and overall safety concerns of your patients, their individualized family structure and their available resources.”
Each of the authors is a member of the Norwell VNA Interdisciplinary Team. Dr. Crossen-Sills serves as Program
Development Manager.Bilton is an Occupational Therapist, Rosebach is a Registered Nurse, Bickford is a Physical
Therapist, and Simms is a Registered Nurse and Clinical Manager.
The Norwell Visiting Nurse Association, located in Norwell and serving the South Shore, provides nursing, physical
therapy, occupational therapy, speech therapy, nutritional counseling, home health aides/homemakers and a variety of
support services and programs to patients of all ages and for all needs. The Norwell VNA has been serving the community
since 1920 providing services to residents in Norwell, Scituate, Abington, Braintree, Cohasset, Duxbury, Halifax,
Hanover, Hanson, Hingham, Holbrook, Hull, Kingston, Marshfield, Pembroke, Quincy, Rockland, Weymouth and Whitman.
For more information about the Norwell VNA and its services, please visit
the web site at www.nvna.org or call 781-659-2342.
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