Northeast Professional Registry of Nurses

Partnering with physicians, hospitals and skilled facilities, bilh at home helps patients make a seamless transition back home in the event of a hospitalization. An experienced team of Nurses, therapists (physical, occupational and speech), medical social workers and home health aides work together to devise a personalized care plan for each patient that may include services such as skilled nursing, disease and pain management, expert wound care, medication management, cardiac and pulmonary care, and physical, occupational and speech language therapy. For the period covered by this filing, bilh at home provided direct care services to patients, including providing more than 208,000 home care visits, across northeastern Massachusetts. In addition, during the fiscal period covered by this return, nprn received a 4-star rating in home health compare in the category of patient experience. Palliative and hospice carenprn offers a range of programs to meet the complex needs of patients and their families coping with advanced illness. These programs include palliative care, bridge-to-hospice, hospice at home, and residential hospice. All patients receive care from an experienced care team that remains the same as the patient transitions through different levels of care. Care team member may include Nurses, social workers, chaplains, physical and occupational therapists, hospice aides and other clinicians upon need or request. Nprn also manages the sawtelle family hospice house in reading, ma, a 10-bed residential hospice facility that provides comfort, care, and emotional support to individuals facing a terminal illness which no longer responds to curative treatment. In addition, as noted further below, the beth israel lahey health (bilh) network of affiliates engaged in significant activities supporting behavioral health in the primary care and other healthcare settings as well as other healthcare initiatives for the communities served. Bilh network accomplishments and activities fiscal year ended september 30, 2022since coming together as a health system, beth israel lahey health ("bilh") has continued to make significant investments and undertake initiatives to improve access for patients and support its surrounding communities. In fy 2022 alone, bilh invested over $8 million in its community health center partners and safety net affiliates, developed accessible patient messaging and education, and invested over $5 million in several behavioral health-focused initiatives. Beth israel lahey health performance network ("bilhpn") continues to optimize its population health-focused initiatives, including those focused on addressing health disparities. Highlights of the system's efforts include: enhanced access for masshealth patients to mitigate barriers in access to care and increase the number of masshealth patients that bilh serves, the system committed to universal network-wide provider participation in masshealth. Specifically, as of october 2020, all bilh hospitals and providers employed by bilh or on whose behalf bilh jointly contracts have applied to participate in some form of masshealth. In fy 2022, bilh signed a new masshealth aco contract with bmc healthnet plan / wellsense health plan that will go into effect in april 2023. As part of this contract, bilhpn will extend participation to all eligible primary care providers ("pcps") who were not otherwise participating in a masshealth aco. While all eligible bilhpn pcps were participants in a form of masshealth, some pcps have previously not participated in a masshealth aco. During fy 2022, bilh developed and refined a multicultural marketing, advertising, and outreach plan with the purpose of expanding access for underserved populations, including masshealth patients, in targeted bilh service areas. Implementation of that plan will occur in fy 2023. Investments in underserved communities bilh hospitals have created strong connections to a network of affiliated hospitals and health centers that provide community-based care to historically underserved populations. In the regions that they serve, the safety net affiliates ("snas") and community care alliance ("cca") community health centers ("chcs") are the cornerstone of bilh's delivery system regarding community-based care for masshealth and historically underserved patients.o cca chcs include bowdoin street health center, charles river community health, the dimock center, fenway health, and south cove community health center. O snas include cambridge health alliance and signature healthcare brockton hospital. Bilh continues to invest in the cca chcs and snas, enabling them to expand their capabilities and care for more historically underserved patients. In fy 2022, bilh invested over $8 million in its chcs and snas, in addition to engaging in regional planning and collaborative program development. These investments represent only a portion of a much larger community benefits investment portfolio that is described in greater detail in this and other bilh network tax filings. Bilh is exploring opportunities with chcs in essex and middlesex counties. For example, bilh has established a telehealth pilot program between physicians at addison gilbert and beverly hospitals and patients at north shore community health center. Commitment to behavioral health care beth israel lahey health behavioral services is the largest mental health and substance use disorder network in eastern Massachusetts. With a focus on community health, bilh behavioral services supports the needs of children, teens, and adults through a range of options, from inpatient care to community-based programs. In fy 2022, bilh invested over $5 million in the following behavioral health initiatives: the collaborative care model, centralized bed management program, and medication assisted therapy ("mat") as of september 30, 2022, 60 of 78 employed primary care practices2 are participating in the impact model, with 12 new sites added from the previous year. The impact model (also referred to as the "collaborative care" model) is a behavioral health integration model, which involves introducing primary care patients who are identified through screenings and direct referrals to an embedded behavioral health clinician. Bilh has continued to expand its bridge clinics at addison gilbert and beverly hospitals, increasing same-day admission for mat patients from 24 to 40 hours per week, obtaining additional staff, and expanding its induction program. Bilh has expanded its system-wide substance use disorder taskforce, defining new pathways for connecting bilh primary care teams with community acute detox and other addiction-based services, increasing the capacity of bilh pcps to prescribe medications in support of office-based addiction treatment, and providing educational trainings to pcps to screen and treat substance use disorders. The practice of mat induction and referral in the ed at bid-plymouth continued in fy 2022, with recovery navigators, an addiction lpn nurse, and a psychiatric np as available resources to patients. Bid-plymouth also continued its partnership with area coalitions to hand out supplies and resources, including narcan, to those patients who are residents of the area and who present to the bid-plymouth emergency room with an opioid overdose. Additional information on behavioral health is below.population health initiatives bilhpn supports and improves access, quality and efficiency of patient-centered care by leveraging best practices in clinical excellence and data analytics to help providers improve patient health outcomes. For example, bilhpn's care management team works with the highest-risk patients in an effort to educate them on their disease, improve medication compliance, and help them navigate the complexities of the healthcare system. The goal of bilhpn's care managers is to improve outcomes for patients while avoiding unnecessary emergency room visits or hospital stays.