Good Shepherd Medical Center, Hermiston, Oregon

Good Shepherd Medical Center (GSMC), located in Hermiston, Oregon implemented an immensely successful care coordination program, called Healthy Living Communities, to help senior citizens live healthy lives in the community. The Health Living Communities program staff, including nurses and community health workers (CHWs), masterfully connected community resources with health care teams.

Positive Outcomes:

• Developed technological innovations for multidisciplinary referral and care plan process
• Implemented multidisciplinary team meetings involving patients in developing care plans
• Increased participation in Healthy Living Communities resulting in increased staffing, including a Care Transition RN and Senior Services Coordinator
• Eight percent reduction of emergency department use among high-risk community members after utilizing CHW in ConneXions program

Top Accomplishments:

The care coordination program made innovative use of technology in conjunction with the new multidisciplinary referral and care plan process. GSMC worked with the information technology team to ensure that CHWs were notified when a high-risk patient visited the Emergency Department (ED). Because the CHW program is based in GSMC's education department, CHWs immediately walked over to the ED and visited with the patient, completed a bedside assessment and initiated intervention. This project was successful in large part due to the leadership and support provided by the dedicated staff of Good Shepherd Medical Center.