A transition that makes a huge difference
Linda, 61, was ready to be discharged from the hospital. Her niece arrived from out of state to take her home. Linda's husband died unexpectedly last October, so she now lives alone. She also no longer drives due to a fall two years ago when she struck her head.
In communities across the nation, metro and rural alike, many older adults like Linda recover after hospital stays alone at home. The days and weeks after a hospital discharge are especially critical for older adults, many of whom can be at risk for falling down. Some don't take or aren't even able to get their medications.
This is not the case for older adults and adults with disabilities living in the Verde Valley. Thanks to Verde Valley Caregivers Coalition in partnership with Verde Valley Medical Center, which provides funding and patient referrals, at risk older adults who are discharged from the hospital are eligible for VVCC's Transitional Care Program.
The program provides supportive services so older adult patients can recover independently in their own homes. These services include transportation to medical, rehab, and other appointments, medication pickup and reconciliation, grocery shopping, assessment of in-home safety needs, loaning of Guardian Angel Medical Alert Units for patients at risk for falling down, linkages to other services, and much more.
VVCC Executive Director Kent Ellsworth, said the strength of the program is the Transitional Care team, which collectively has over 378 professional years of health care experience. "We maintain a qualified staff of licensed RN/Nurse Practitioners, RN PHN, and experienced RNs along with a group of volunteers which includes retired RNs and other retired healthcare professionals."
Because of VVCC's program, Linda received the supportive services she needed to recover after her hospital stay in her own home. Linda's Transitional Care volunteers provided transportation to and from medical appointments, helped her grocery shop from an electric cart, and linked her with other agencies for in-home care, medical insurance, and cheaper medication costs.
Ann Eller, VVCC's Transitional Care Program manager, says the services the program provides are lifesaving. "In some cases, these patients have nowhere else to turn. We are providing essential services.
"There is no other program like this in the U.S. today that provides as many services as we do" Ann adds. "We take care of the whole human being. Our clients are always able to receive services and never get discharged from our organization."
VVCC's 30-day Transitional Care Program has impacted VVMC's re-admittance rate for Medicare-eligible patients, making VVMC's rate one of the lowest in the nation.
Betty, 85, has been assisted by VVCC for many years. She uses one of VVCC's Guardian Angel medical alert pendants, and recently had surgery, which required specialized support from the Transitional Care team. While Betty was in the hospital, VVCC also helped take care of her dogs through its Pets Count Too! Program, funded by a grant from Banfield Charitable Trust.
"There is nothing I have asked for that they (VVCC) haven't come through with," Betty said. "I am overwhelmed by how gracious, caring, and generous everyone has been. They are God's angels."
Ellsworth said that as our older adult population grows, so do the health challenges.
"VVCC has mobilized its resources in direct partnership with VVMC and has thereby demonstrated that we can improve health outcomes for the people we serve while drastically reducing hospital re-admissions."