The Area Agency on Aging 8 (AAA8) and the Memorial Health System are piloting a free Care Transitions service to assist patients when they are sent home from the hospital.
The Care Transitions program is designed to assist patients as they transition from the hospital to home and help reduce recurrent hospitalizations by providing key resources. Participating patients are supported by a Transitions Coach for four weeks after discharge. The goal is to empower patients and caregivers with tools, skills and information to develop long-lasting health management skills.
“Care Transitions is a program that has been tested in other states and proven to be effective in helping prevent folks from returning to the hospital,” said AAA8 Director Rick Hindman. “We are very excited about the Marietta area pilot and the partnership it is creating across the health system.”
The Transitions Coach works with the family to identify caregiver supports and review key needs as well as to refer to a variety of community resources. Key components also include a close monitoring of medication management, getting patients to key follow-up medical visits and keeping good records.
According to Memorial Health System CEO Scott Cantley, “Care Transitions supports patients in learning more about their illness and healthcare needs. We encourage our patients to ask questions to better understand and manage their illnesses, to know their medications, and to communicate and follow up with their doctors.”
“There is an obvious underlying goal to reduce unnecessary hospital readmissions and reduce Medicare costs, but more importantly, the goal is to put in place proven supports for individuals to help them heal and be at home – where most people say they would rather be. The Area Agency on Aging is focused on connecting individuals to key home and community-based care resources,” added Hindman.
Marietta-area resident Patricia Uhl benefitted from the Care Transitions program following her recent stay in the hospital. “It was very helpful to have these nice people help me,” said Patricia. She explained that she returned to Marietta to be near her three daughters following 18 years in Florida.
The Care Transitions program is supported by the Southeast Ohio Aging & Disability Resource Network (ADRN) and provided at no charge to patients. For more information on the AAA8 or ADRN, contact 1-800-331-2644 or visit www.areaagency8.org.