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S ERVING AS MANY as 650 patients a year, the program has a large geographic area, including all of Southeastern Massachusetts and East Bay Rhode Island. Its wide appeal stems from a combination of clinical excellence, patient-centered care and close collabora- tion with hospitals and referring physicians. "We are advancing our clinical practice using specific tests and measures, such as the gait speed test, to assess patients' progress and demonstrate their need for home care services," says Lisa Santos, PT, MS, Program Director of Rehabilitation at Southcoast VNA. "Very few if any of our patients have required rehospitalization." In the Hands of Professionals The skilled providers in the program include physical therapists, occupational therapists, nurses, social workers and home health aides. Southcoast VNA makes it a priority for staff to remain on the leading edge of care, Santos notes, and employees are involved in continuing education in their areas of specialization. Most of the 50–60 patients seen each month have undergone joint replacement and are eager to return to normal activities. The therapists, many with master's degrees and clinical doctorates in their fields, match patients to the physical and occupational therapies that make that possible. "Our Orthopedic Specialty Program is tailored for patients recovering from joint replacement surgery," Santos says. "We collaborate with physicians to ensure their protocols are implemented and provide regular status reports on their patients' progress." Constant Vigilance Many joint replacement patients are elderly and have comorbidities that can increase the risk of rehospitalization. Southcoast VNA therapists are trained to assess patients' conditions thoroughly as part of their home care visits. Therapists assess for signs and symptoms of blood clots, infections and postoperative complications, then utilize preventive measures where appropriate to minimize any need for rehospitalization. As an example, a limb girth assessment may be conducted to monitor edema, and vital signs are taken at every visit, Santos notes. Care When It's Needed Indeed, prompt interactions charac- terize all aspects of Southcoast VNA's Orthopedic Specialty Program. Southcoast VNA offers preoperative consultations by phone or in home to help prepare for surgery. Upon patient discharge, a physical therapy home visit is made within 24 hours. Therapy staff are available to visit patients seven days a week. To refer a patient to the Southcoast VNA Home Care Program, please call 800-698-6877 or visit www.southcoastvna.org. ■ "At Southcoast VNA, the patient experience is very important to us. Our highly trained and experienced team of rehabilitation professionals employ best practices and always strive for clinical excellence." — Lisa Santos, PT, MS, Program Director of Rehabilitation at Southcoast VNA SOUTHCOAST VISITING NURSE ASSOCIATION'S (VNA) HOME CARE ORTHOPEDIC SPECIALTY PROGRAM HELPS PATIENTS MOVE SEAMLESSLY ACROSS THE SPECTRUM OF CARE. Southcoast VNA: Transitioning Patients Smoothly From Acute Care to Outpatient Independence By Jennifer Webster