Delaware County Transitional Care Model by JVWN7S7J


									Delaware County
Transitional Care Model

“Making it Easier for Individuals to Navigate
their Health and Long Term Care though
Person Centered Systems of Information,
Counseling and Access”

Laying the Foundation

   AAA - Delaware County Office of
    Services for the Aging – (COSA)

   Crozer Keystone Health System
    (CKHS)– Senior Health Services

   AAA in southeastern PA
   Department of local government
   1 in 5 residents are over age 60
   Provide traditional AAA services such as
    senior centers, nutrition services, legal
    assistance, volunteer opportunities, I&R,
    LTC assessment, Aging Medicaid Waiver,
    FCSP, PS, Ombudsman, state funded care


   Operates 5 of the 7 hospitals in the
   Operates 4 of the 6 inpatient
    hospitals in the County
   Senior Health Services is a
    department within the Crozer
    Keystone Health System


   For some time COSA and CKHS –
    Senior Health Services have worked
    together in efforts to impact a
    positive change in the culture
    between the acute care setting and
    AAA supported home and
    community based services

What we Found

   Perceptions are hard to change
   The fit was perfect
   It was the appropriate time
   We are consistent with the national
   We are able to build on existing

Foundation in Place
   2006 COSA was designated as a
    Community Choice County by the
    PA Dept of Aging
   2008 Nursing Home Transition
    program implemented
   2009 grant to develop an ADRC for
    the County
   2010 COSA member of the CKHS
    Heart Failure Transition Team

2010 Taylor Hospital
Discharge Project

   All referrals with 4 diagnoses (CHF, MI,
    COPD, Pneumonia) referred to Senior
    Health Services by hospital discharge and
    ER staff
   Senior Health Services refers to COSA for
    assessment and services
   Senior Health Services follows consumers
   Senior Health Services/COSA Intake –
    Assessment Program Manager
    communicate daily

Foundation Laid

   By working very closely with CKHS
   The Transitional Care project is
    building on what we have in place
   The overriding goal of the project is
    to “Prevent re-hospitalizations for
    seniors identified as high risk”

Transition Grant 2010

Transitional Care Map

                                                    APN visits                   APN conducts comprehensive
       Patient admitted to                          patient in                   assessment of patient’s and
       hospital – identified                        hospital within              family caregiver’s goal and
       within 24-48 hours                           24 hours of                  needs, and initiates
                                                    enrollment                   collaboration with patient’s
                                                                                 physicians, including PCP
        Patient is assessed
        by COSA Assessor                           APN visits patient            APN works with the COSA
        for appropriateness                        daily during                  care manager to design and
        and program                                hospitalization –             coordinate transitional care
        placement eligibility                      collaborates with             plan, discharge plan and
                                                   health care team              arrangement of COSA
                                                                                 services (based upon
       Patient is screened by                                                    eligibility)
       APN based upon
       program criteria and risk
       factors. APN contacts                                                     APN is available seven days
                                                    APN visits patient
       SHS Triage Clinician for                                                  per week (includes at least
                                                    at home within
       additional patient history                                                weekly home visits during first
                                                    24-48 hrs post IP
                                                                                 month, and at least weekly
                                                                                 telephone outreach
                                                                                 throughout intervention)
        APN and COSA
        Assessor determine
        patient eligibility and,
        enrolls patient into
                                                                         APN initiates at
        program                             APN and COSA Care
                                                                         least monthly                  APN
                                            Manager implement
                                                                         telephonic                     provides
                                            care plan, continually
                                                                         outreach to
                                            reassessing patient’s                                       additional
                                                                         monitor                        intervention
                                            status and the plan with
                                                                         progress and                   to patients
                                            the patient, family
                                                                         communicates                   identified at
                                            caregiver and PCP
                                                                         regularly with
                                             (Average length of                                         risk for poor
Adapted From: The Transitional Care         intervention is 2 months,    COSA Care
Model: Translating Research Into Practice
                                            post-hospitalization         Manager                                   11
and Policy Naylor, M, Ware, M. (2010)

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