Lutheran Homes Society (LHS) has introduced a new program designed to help individuals transition back to a home-based setting after a stay in a hospital, rehabilitation unit or skilled nursing facility.
The LHS Care Transitions program has been implemented throughout the organization’s long-term care and housing and community services ministries.
Lutheran Homes Society is setting up a service line “without walls,” which means that once an individual enters the LHS system, care will be coordinated for them as long as it is needed. Not only does the program expand services beyond the walls of LHS long-term care and rehab facilities, but it has also been proven to reduce the readmission rate to hospitals.
|LHS Care Transitions Coordinator Tricia Fischer
consults with Emory Hagermen in his home.
“Lutheran Homes Society has had great success with the Care Transitions program,” said Amanda Schroeder, LHS Executive Director of Home and Community Based Services. Since July 1, 2012, there have been 91 cases opened, and LHS has experienced a 91 percent success rate at decreasing hospital readmission rates for these individuals.
“The program offers a continuum of service that demonstrates our care for those we serve after they leave our facilities,” said David Roberts, LHS President/CEO. “It concentrates on educating individuals so they gain the knowledge and skills necessary to successfully remain in their home and avoid returning to a medical facility.”
The Care Transitions program expands discharge planning efforts to offer person-centered care and care coordination in the least restrictive home-based setting. To operate the program, LHS has hired two Care Transitions Coordinators – Tricia Fischer and Jackie Garcia.
Each coordinator works one-on-one with individuals from the time they are discharged home, focusing on the specific care needs and wishes of each individual. Health and safety concerns and each individual’s right to self-determination are key factors considered by the coordinators when they make weekly home visits to clients throughout northwest Ohio.
The program focuses on four primary areas of intervention: medication self-management, use of a dynamic Personal Health Record to ensure continuity of care, follow-up with primary care physicians and specialists, and recognition of red flags and response options. Coordinators also organize care services with home health providers, primary care physicians, and other medical professionals listed on discharge plans, as well as family, friends, and authorized representatives.
“Many clients are overwhelmed with the responsibilities of returning home and the sheer number of arrangements that need to be made,” explained Tricia. “We are here to empower clients to take control of their own care.”
The program has no age or income restrictions. Individuals who have not been in an LHS facility can also benefit from the care coordination services. For more information on LHS Care Transitions, call 1-877-646-4050.
Lutheran Homes Society is a social ministry organization based in Toledo, Ohio, that has been serving the needs of youth and elderly since 1860. LHS operates four long-term care facilities that house rehabilitation units, including Lutheran Home at Toledo, Lutheran Home at Napoleon, Lutheran Memorial Home in Sandusky, and Lutheran Village at Wolf Creek.
LHS also has 12 independent living senior communities, a community services ministry, and a group home program for troubled youth.
LHS Care Transitions Coordinator Tricia Fischer consults with Emory Hagerman in his home.
Florence Parton (right) is one of Coordinator Jackie Garcia’s successful graduates of the LHS Care Transitions program.