Suburban Hospital registered nurse Leni Barry is always looking for new recruits to “wellness Wednesdays” at the Margaret Schweinhaut Senior Center in Montgomery County, Md. Take, for example, the elderly gentlemen who gather around the center’s “pool hall” lounge.

Barry is at the center every Wednesday for her five-minute “Know Your Numbers” consultations with senior residents. She checks their vital numbers – blood pressure, cholesterol, BMI and blood sugar – and updates their medical wallet card that tracks the health information. She’s also at the center every third Wednesday to lead a diabetes management support group.

HeartWell NursesOver time, Barry managed to cajole the pool players to join her Know Your Numbers team. “I wouldn’t go in there because it’s a little dicey, but I would peek my head in and ask, ‘Who’s daring to come down the hall and get their numbers checked?’” she says. “Now, we have a huge following from the pool hall. They are comparing their numbers and becoming much more knowledgeable about their health. They are trying to outdo one another with their numbers.”  

Barry is one of three HeartWell nurses who visit four senior centers in the county every week to conduct health screenings, provide counseling, organize chronic disease support groups and plan community health-focused educational seminars. 

Bethesda, Md.-based Suburban Hospital launched the program more than a decade ago to help elderly county residents manage their heart disease. It expanded the services to include helping seniors manage diabetes and other chronic conditions. HeartWell nurses served more than 10,000 people last year.

The program is designed to “keep people out of the hospital, feeling comfortable managing their chronic condition and helping them understand how to have confidence in doing that on their own,” says Monique SanFuentes, the hospital’s director of community health and wellness.

Sanfuentes says keeping elderly patients out of the hospital and staying healthy in the community requires collaboration with other hospital clinicians and caregivers, and a network of strong community partners that includes senior centers, county agencies, schools, churches, clinics and the YMCA.

“It’s important that we work collaboratively so we can maintain and build upon that continuum of care,” she says. As part of that effort, the nurses also are working with “ambassadors” or representatives of the county’s senior villages – civic-minded groups of neighbors who support aging residents who want to remain in their own homes.

“We know we have prevented people from returning to the hospital or from having a far more serious medical problem,” says HeartWell nurse Sharon Shapiro. “The idea isn’t to say goodbye when they leave the hospital, but that we will see them again when they are home.”

Among other initiatives, HeartWell nurses volunteer every week at the MobileMed/NIH Heart Clinic program. For the past seven years, Suburban Hospital has partnered with Mobile Medicare Care Inc. and the National Heart, Lung and Blood Institute to expand access to specialty care to low-income patients.  

The nurses say patients develop a rapport with them and feel comfortable asking questions. “We’re not just taking their blood pressure,” says nurse Mary Flynn. “We talk about nutrition and exercise and try to focus on the whole person and that helps build trust. They look at us as part of their health care team, and that’s the most rewarding part of the job.”

Adds nurse Barry: “It’s a small program, but we have a big impact.”