The region’s only Neighborhood For Health is located at the North Adams Campus of Berkshire Medical Center, for area patients just discharged from BMC. For the first time in our community, patients are receiving comprehensive out-patient medical care all assembled under one roof, as well as the social and community services needed to regain their health.
The Neighborhood For Health is located on the second floor of the North Adams Campus of BMC, which has been modified for the initiative. BHS also hired a new Neighborhood For Health team.
“This initiative enables us to pull all of the critical pieces together for patients, so that they can return to the best health possible when they get home from the hospital,” said David E. Phelps, president and CEO of Berkshire Health Systems. “It ensures that all of their care is easily accessible in one location, completely coordinated, and carried out by a team that is all working together in partnership with the patient.”
Delivery of high quality healthcare services through the Neighborhood For Health is funded in part by a $3 million CHART grant that BHS received for its North Adams campus from the Massachusetts Health Policy Commission, with additional investments and infrastructure from BHS. Enhanced behavioral health services will also be provided in collaboration with the Brien Center.
“This is a very innovative model of patient care that begins with an enhanced plan at discharge, when patients need the most support to regain their health,” said Diane Kelly, Chief Operating Officer at BMC. “This unique approach manages their care with a team that is dedicated to each patient’s needs, working in close collaboration with the primary care physician. This team will support them every step of the way during their recovery.”
The new medical services include:
“Among the goals of the Neighborhood For Health is to provide not only high quality healthcare, but also identify and eliminate whatever barriers may prevent an individual from being healthy,” said Mark Pettus, MD, Director of Medical Education and Medical Director of Wellness and Population Health at BHS. “For some, that may be transportation to care. For others, it may be access to nutritious food or a safe environment. That’s why Social Workers and Community Outreach Workers are an important element. The Neighborhood For Health will take a holistic approach to each patient by creating an individualized care plan focused on the patient’s needs and goals that will lead them back to better health.”
The process begins as soon as a North Berkshire resident comes to BMC for care. Their zip code will activate a call to a Care Navigator at the hospital, who will visit the patient while still in the hospital, confer with the patient’s hospital healthcare team, and work with the patient to prepare a care plan to meet the patient’s medical and social needs once he/she goes home. The Care Navigator will also arrange the first visit to the Neighborhood For Health upon discharge, and ensure that all of the right clinicians and community support are there to meet the patient.
“When people are sick, they often suffer from behavioral health issues as well, especially if they have a chronic health condition such as congestive heart failure or diabetes,” said Alex Sabo, MD, Chairman of the BMC Department of Psychiatry and Behavioral Science. “That’s why it’s so important to have behavioral health services as part of the Neighborhood For Health. We want to make sure that patients receive the emotional support needed to get well.”
Only the Northern Berkshire region met the eligibility requirements for a CHART grant to help fund a Neighborhood For Health. While the primary focus is on Northern Berkshire patients discharged from the hospital, BHS expects the program to evolve to the point where primary care physicians can also refer patients who would benefit from these services.
“Creating a Neighborhood For Health in North Berkshire is part of our on-going plan to bring proven, high quality services to areas most in need of them,” Phelps said. “This program leverages the full strength of our community’s healthcare system.”