Androscoggin Home Care and Hospice’s Home Care program offers a variety of services designed to care for patients recovering from illness or injury who wish to do so in their own homes.

Registered nurse Brenda Czado, director of Home Care, has been with AHCH for more than 20 years. “AHCH has a team of nurses, therapists, social workers, personal care attendants, volunteers and other specialists,” she said, “who are committed to trying to keep people in their homes — safe and where they want to be.

“AHCH serves a homebound population with varying degrees of needs,” explained Czado, and whether a patient is recovering from surgery, an acute or chronic injury, or a long-term illness, the availability of appropriate home care services is integral to every aspect of each patient’s recovery process. It also provides a welcome respite and a reassuring support system for the patient’s family.

Among the many customized home care services provided by AHCH, three are particularly progressive.

Telehealth Monitoring Services

“Telehealth allows us to monitor patients on a daily basis,” said Czado, which includes remotely “checking weight, pulse, blood pressure and oxygen saturation levels.” It is intended to supplement, not replace, traditional nursing care visits, making it possible for nurses to more closely follow a patient’s progress and communicate quickly with the doctor as needed.

The patient is supplied with a monitor that transmits information regarding the patient’s health status to telehealth nurses on a daily basis. The telehealth nurses monitor the readings and determine if a nursing visit is needed, or whether a family member or the docotr needs to be called.

Using this system, the telehealth nurses are also able to ask patients a set of personalized questions, such as whether they have taken their daily medications, are having difficulty breathing, or would like the nurse to call.

“We’ve seen really good results in preventing hospitalization,” said Czado “and this tool is an instrumental part of our chronic care disease management program.”

Chronic Care Disease Management

“Many AHCH patients have one or more chronic diseases such as heart failure, diabetes, COPD and depression” said Czado.

Members of the AHCH staff are provided with extra training regarding these underlying diseases. The user-friendly AHCH website defines the Chronic Care Program as one in which “certified staff act as coaches to teach and encourage patients how to manage their chronic diseases more effectively.”

The success of this program can be attributed, in part, to utilizing “motivational interviewing.” Motivational interviewing is a listening technique wherein the clinician helps the patient to set their own goals regarding the appropriate care for their particular condition or disease.

This increasingly popular and nationally recognized trend in home health care is patient driven in that it focuses on what is most meaningful to the patient, as opposed to provider driven wherein the patient is told by others what is most appropriate and preferable.

For example: A patient may wish to spend time and be able to play with a grandchild. The care provider will then identify, on a week-to-week basis, what physical milestones the patient needs to reach in order to make that wish become a reality.

“It identifies a very specific goal,” explained Czado, “and the process of achieving that goal is broken up into small steps,” similar to a behavioral therapy model. “This technique helps with the patient’s level of enthusiasm, commitment to the treatment plan, and overall recovery.”

Community Care Team

The Community Care Team is part of a multi-payer grant pilot project offered through the Centers for Medicare and Medicaid, and the state of Maine. In Maine, the physician’s practices participating are called Health Homes and Patient Centered Medical Homes.

The Community Care Team focuses on the top 5 percent of patients in the practices who, for whatever reason, require the most in-hospital support or treatment.

Physicians identify patients who demonstrate a high utilization of the health care system. “These patients are those who have the greatest frequency and need for care,” said Czado.

Once a qualifying patient is identified, the identifying physician makes a referral to the CCT, and the CCT affiliated with AHCH makes contact with the patient, offering to perform a home assessment to determine what obstacles to good health and appropriate use of the health care system the patient is facing, as well as what obstacles the patient is willing to work on.

According to Czado, “Factors which might cause these patients to seek care include homelessness, a lack of food, or the simple fact that they have always used the emergency room as their primary source of health care.” A patient’s “participation in this project,” she added, “is voluntary.”

For a more complete listing of home care services provided by Androscoggin Home Care & Hospice, or to see if you or your loved one might benefit from skilled home care services, please visit www.ahch.org or call AHCH at 207-777-7740.


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