Care Transitions
Marge, an older woman, had back surgery and was sent home without instructions for how to care for herself and without home health care services. She had great difficulty getting out of bed to use the bathroom, she could not take care of the surgical wound on her back, and she could not prepare meals for herself. She was frightened and did not know who to call for help.
Any adult child of an aging parent or caregiver can tell you about problems in care transitions of patients
discharged from the hospital with complex care needs.
The new care transitions services will be delivered by the Community Concern’s Senior Care Management Program in collaboration with TLC Health Network. A grant from the Community Health Foundation of Central and Western New York, will build a lasting collaboration between Community Concern of WNY, Inc., the leading provider of senior care management services and the TLC hospital system to reduce hospital recidivism and increase independent living skills for seniors in Southern Erie County.
Care transition problems are magnified in rural areas of Western New York. The lack natural support systems, limited public transportation, challenging weather, strong self-sufficiency attitudes often add to the mix of barriers that prevent frail, rural seniors from receiving the care they need.
Transitional coaching is a natural extension of our mission and services already provided by the eldercare
specialists at Community Concern’s Senior Care Management Program. Frail, elderly TLC patients
discharged from Tri County Hospital (Gowanda, NY), Lake Shore Hospital and Skilled Nursing Facility
(Irving, NY) who resides in the rural towns of Evans, Brant, Collins, North Collins and Eden will receive“transition coach” visits after discharge. Upon consent of the patient, the discharge plan will be reviewed
with a CCWNY care manager who will make a home visit within two to five days of the discharge.
Medications and follow-up care plans will be reviewed with the patient by the care manager. Medication
discrepancies and / or barriers to follow-up care will be identified and solutions will be negotiated with the
patient and his or her caregivers.
A minimum of one follow-up phone call will be provided to assess compliance. If additional needs (e.g. nutrition, home safety, financial) are identified a full assessment will be conducted and care plan developed with the patient and his or her care givers. Care management services will be provided at no cost to the patient.
