The
collaboration is based on the Mary Naylor Model of Care Transitions, an
evidence based program from the University of Pennsylvania School of
Nursing. Using this model as a framework, JFS and Holy Redeemer have
hired two Health Coaches, who are experienced nurses, to assist patients
navigate through care transitions from the hospital to Medicare
certified Home Care, to Long Term Care. The Coaches meet the client
while they are still in the hospital and make their follow up medical
appointments within one week of hospital discharge. They keep a close
watch on the client with home visits, telephone contact and accompanying
the client to the physician to ensure that the client discusses all
pertinent issues with the physician and follows the recommended course
of care and medication. The goal is to avoid re-hospitalization during
this four month period.
At
this early stage of the program, there are currently thirty clients
enrolled in the program. The Agency is grateful for these grants that
will help the Older Adult Services Department expand and improve the
quality of services to the Union County clients who have serious medical
problems and who are over the age of sixty.
