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Supporting patient ‘transitions’

Our Agency is constantly engaged in identifying opportunities that allow us to reach as many individuals as possible who are seeking long-term care services.

Our mission is to assist them with maintaining independence and personal choice through resource options and services.

One opportunity we are working diligently on involves patients who are being discharged from local hospitals. Currently, we are partnering with a number of our local hospitals and supporting their efforts in reducing avoidable re-admissions as part of the Affordable Care Act.

Through the services our Agency provides, we work with social workers and discharge planners on education for patients prior to their discharge.

We share with patients information surrounding the resources that are available to help support their health and well-being at home, as well as reduce their chances of unnecessary re-admissions to the hospital.

For instance, say a patient is discharged home after a hospital stay due to pneumonia – our Agency has trained staff who can meet with them while in the hospital, or at home shortly after discharge if they prefer, to discuss the options available that supports their recuperation at home.

Area Agency on Aging District 7 licensed staff can assist with referrals to local providers or, if eligible, can authorize services which might include home care, personal care assistants, home-delivered meals, transportation, emergency response systems and more.

Most recently, three of our nurses were certified as “coaches” and trained in “care transitions,” which basically defines a shift between a care provider and care setting.

One “care transition” might be defined as a patient receiving care from a primary care physician to a referred specialty physician.

Another “care transition” might involve a hospital admission that is discharged to a nursing facility or even home.

In their role as a coach, our trained nurses assist patients through that “care transition” from the hospital to home or nursing facility, supporting the patient’s participation and understanding of their health and recuperation.

The goals of our coaches are to increase communication and exchanges of health information; empower patients and their families; promote health information exchange across care settings; and implement interventions to improve quality and safety.

We are excited about the opportunities available to establish partner relationships with our local hospitals to help support patients and those in the community who want to remain at home.

We are looking forward to working with more hospitals, nursing facilities, and physicians on ways we can best support them and, most importantly, their patient.

If you know an older adult or someone with a disability who wants so to stay in his or her home, or if you have questions about home and community-based services, please do not hesitate to give us a call.

We have trained nurses and social workers who are ready to assist you with determining what services are best suited for your situation and developing a care plan that meets your needs.

Pamela K. Matura is executive director of the Area Agency on Aging District 7. The non-profit agency serves senior citizens in Adams, Brown, Gallia, Highland, Jackson, Lawrence, Pike, Ross, Scioto and Vinton counties.