Care Transitions

Community Concern of wny care transitionMarge, 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.

Community Concern of WNY Receives Second Transitions of Care Grant

 The Community Health Foundation of Central & Western NY awarded Community Concern’s Senior Care Management Program a second grant to expand the Care Transitions model to caregivers. 

“Family caregivers are the ‘silent partners’ in health care delivery to seniors” says executive director, Jerry Bartone.  “Family members make important contributions to insure quality, safety and adherence to their loved-ones’ preferences as they navigate the complex health and human service system.  The Improving Transitions of Care through effective Family Caregivers Partnerships grant will offer support and guidance to family members of the nearly 600 seniors who receive Community Concern’s services.”

The Senior Care Management Program achieved acclaimed outcomes with the first Care Transitions initiative.  Transitions coaching reduced hospital readmissions by 50%.  It also provided outreach and case management to over nearly 200 seniors at a time when they are most frail, upon discharge from the hospital.  Transition coaching is the leading transformational model to reduce healthcare costs.  There is a bill currently in congress to make this model a national healthcare priority.

The goal of this second grant initiative is to help caregivers better manage care transitions for their elderly loved ones.  Case managers will provide coaching to help the caregiver define a clear, understandable role in the transition from one level of care to another.  We will also provide clients and caregivers with information concerning advanced directives, in the event that a client experiences an illness that makes them unable to communicate their wishes.