Jackie Garcia (right), a coordinator for Lutheran Homes Society’s Care Transitions, helps Florence Partin look over her medi- cations.
serve more than 100 clients each month.
Care without walls L
ast year after having both hips replaced, Florence Partin, 84, smoothly transitioned back to
living at home, with the help of Lutheran Homes Society in Toledo, Ohio. Now the member of First St. John Lutheran Church, Toledo, is back to her active life, which includes volunteering at a hospital. “I had such good help when I was recovering,” she said. “And I wanted to get better, so I was a good patient.”
Partin ticked off a list of services LHS Care Transitions coordinator Jackie Garcia provided: health prog- ress checks, walking through her home to ensure safety and a willing- ness “to answer any questions.” Garcia, a licensed practical nurse, helps clients like Partin follow
Hunter is a section editor of The Lutheran. 36 The Lutheran •
www.thelutheran.org
Lutheran agency helps Ohio seniors recuperate By Elizabeth Hunter
discharge and medication instruc- tions so they can remain at home. “For every person I’ve come across there’s no place like home. They sleep better and feel better. It’s the environment they want to be in as long as possible,” she said. Toward that goal, Garcia ensures “follow-up appointments are made, medications are called into the phar- macy and picked up, and any ser- vices are going smoothly,” she said. “If there’s a service lacking, we link [them to] it.” Tricia Fischer, another LHS care coordinator, said it’s surprising how many people “don’t even open up that folder [of discharge informa- tion]. So if they accept a home visit, we get those notes and go through all the discharge instructions to see they have everything they need.” Together Garcia and Fischer
Begun in 2012, Care Transitions (LHS calls this “care without walls”) continues service after people are discharged from one of its long-term care and rehabilitation facilities or from a hospital. For most this means home visits during the 30 days after discharge, but sometimes a client needs services for a longer period. Amanda Schroeder, LHS executive director of home and community-based services, said Care Transitions is based on a model developed by University of Colo- rado professor Eric Coleman. “We ask what they need and give them tools to be successful in the setting they want to live in,” she said. That’s a win-win-win approach for everyone. “People better under- stand management of their health care,” she said. “We’re seeing hos- pital readmissions decrease [to only 4 percent]. And our facilities benefit because hospitals (which receive reimbursement based on individuals not being readmitted) want to release patients to facilities that have a care coordination system built in.” Looking at the trends, Schroeder sees nursing homes becoming more like rehabilitation facilities, while “more people move back into their homes, whether that’s independent living or something else. Histori- cally, individuals [who] live in nurs- ing homes for three months or more can’t afford the cost to maintain their health, their home and they get stuck. Care Transitions is a way to help change that.” Garcia still continues to visit Par-
tin occasionally—now as a friend, not a care coordinator. “She’s pretty insistent on me continuing to visit,” Garcia said with a laugh. “And we both have the gift of gab.” Partin said, “I like her to stop by when she has time.”
COURTESY OF LUTHERAN HOMES SOCIETY
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