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Returning Home A solution for healthcare providers and family caregivers

Returning Home A solution for healthcare providers and family caregivers. Each Home Instead Senior Care franchise is individually owned and operated May 2012. What are Hospital Readmissions?. Patients discharged from hospital and readmitted within 30 days .

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Returning Home A solution for healthcare providers and family caregivers

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  1. Returning HomeA solution for healthcare providers and family caregivers Each Home Instead Senior Care franchise is individually owned and operated May 2012

  2. What are Hospital Readmissions? Patients discharged from hospital and readmitted within 30 days. Current Statistics for Acute readmissions within the BOP 12% of Adults over 65 are often readmitted 13% of Adults over 75 are often readmitted

  3. Two Areas to Reduce Readmissions: • Medication mis-management/non-compliance • In Home Safety

  4. Why are they are problem to the DHB • Re-admissions are a cost • Re-admissions block beds • Re-admissions reduce the service to elective waiting lists

  5. Conditions with Highest Occurrence of Readmissions • Comorbitity • Congestive Heart Failure • Pneumonia • Diabetes

  6. Why Home Instead Senior Care is Entering the Picture: • Can help hospitals reduce readmission rates • Keep individuals safe at home with the quality services we already offer • Can assist with discharges to ensure beds are made available as soon as possible

  7. Returning Home Core Care Services • Discharge Plan Implementation • Transportation to Doctor Appointments and Rehabilitation • Home Safety Inspection • Medication Management • Follow-Up Doctor’s Appointments • Prescription Pick-Up • Early Warning Signs & Alerts • Nutrition: Meal Preparation • Assistance with Personal Care • Emotional & Social Support (Companionship Care) • Record Maintenance

  8. 30-Day Plan of Care Book

  9. Care Coordination by Transitional Care Manager and Reporting • Clinical experience or training • Interface with Hospital and Discharge professionals • Selection & Supervision of Support Worker(s) • Post-Discharge Reporting & Communication with Hospital Daily Care Journal: • Plan of Care, Medication Record, Appointment Record, Warning Sign Observations, Nutrition Record, Hazard Identification Reporting • Exception Reporting as Necessary

  10. Following Services Offered as Necessary • Home Preparation: Home Safety Inspection; Restock Groceries; Etc. • Transportation Home • Client Orientation • Home set up to Support Independence • Communication with Family • Support Worker

  11. Transitional Support Worker: • Transitional Care Experience • Transitional Care Training • Basic/Advanced/Safety Home Instead Support Worker Training • Case Management Orientation • Police Checked

  12. Measurement and Cost • The success of this transitional care service will be measured based on a mutually agreed upon standard. • Possible measures include: • Readmission rates scaled by week post-discharge compared with hospital baseline • Readmission ratio of transitional care cost and readmission rate • Transitional Care Model Allows for Complete Flexibility Based on Care Needs & Client Circumstances. Rates vary depending on clients needs

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