Published on June 14, 2016

It takes a team

Helping nursing home residents stay out of the hospital

Putting competition aside and working together for the good of patients.

Chest PainThat’s the mission of the NorthEast Cross Continuum Team (NECCT), a special group dedicated to helping nursing home residents avoid repeat stays in the hospital.

Why these patients in particular? Many count on Nazareth Hospital for care. They often arrive with multiple health problems. That puts them at high risk for a return visit.

A patients-first approach

Once a month, the NECCT brings together representatives from Nazareth Hospital and nine nearby nursing homes. Home health agencies and community groups also participate. Everyone shares their strategies for reducing readmission rates. That itself is a breakthrough.

“Typically, nursing homes compete,” says Elaina Kim Watts, MHA, BSN, RN, CMM, Director of Care Coordination at Nazareth Hospital. “So it’s unheard of, really, that people from so many homes are in the same room and talk so candidly about challenges they face and how to overcome them.”

Residents who return to nursing homes after a hospital stay also share their insights on improving readmission rates. “We want to know: Is there anything we can do better to help you stay well?” Watts says.

This feedback has spurred the hospital to put important practices into place.

An example: Ensuring a quick exchange of crucial information about a patient’s medical history between the hospital and nursing home.

The result: Our readmission rates for nursing home residents are falling.

The NECCT, which was launched in 2013, was Watts’ idea. She’s heartened by how much the NECCT is already helping patients.

“Every avoidable readmission we prevent means that a patient’s life improved,” she stresses.

Read more about how Nazareth strives to keep seniors healthy. Go to