Partners Home Care has unveiled a new unique Chronic Care Management Liaison Program out of the new MGH/North Shore outpatient complex in Danvers. The program's goal is to create a partnership with physicians and patients to successfully manage chronic conditions such as diabetes, hypertension, heart or respiratory disease. With the opening of MGH/North Shore, Mary Trocki, RN, PHC Liaison, specially trained in chronic care management, will be housed in the new facility, and will be easily accessible and prepared to work with physicians and clinical practices. After the initial program launch at MGH North, plans are to expand this program to other communities within the Partners Home Care service area.

"This is a 'high touch' system of healthcare delivery," said Kathy Duckett, RN, Director of Clinical Programs at Partners Home Care. "Thanks to the vast array of expert clinical specialists and technology resources available through Partners, Mary, as a Chronic Care Management liaison, will have access to cardiac nurse practitioners, home health nurses, therapists, wound care specialists, diabetes educators, and other disciplines and technology necessary to managing patients' care."

Case managers and care coordinators in the hospital help meet the needs of inpatients transitioning to the community setting. Outside the hospital walls, though, physicians and clinical practices may not have staff or the expertise available to provide important health management connections for their patients. As a result, those with chronic conditions may be missing out on vital healthcare and community services. With experience in home care services, chronic care management and working with a network of highly-skilled liaisons, Mary will serve as the health connector, establishing a link between physician, patient, and the necessary clinical and community services. With this new program, continuity of care will be assured, and individuals with chronic illnesses will be allowed to maintain healthy independence.

In his June 15th address to the AMA, President Obama stated, "Because our health care system is so complex and medicine is always evolving, we need a way to continually evaluate how we can eliminate waste, reduce costs, and improve quality." With healthcare reform looking to finally becoming a reality, now more than ever in the past physicians need access to community resources, resources that this program can provide. PHC's innovative Chronic Care Management Liaison program can help keep patients in their homes through effective and efficient care, and avoid moving into a higher, more costly level of care. Additionally, the quality of life is much improved for patients when they remain in the community.

We invite you to contact Partners Home Care for more in-depth information about this exciting new program. Please feel free to contact Mary Trocki at mtrocki@partners.org