“Re-hospitalizations are incredibly disruptive for seniors and their families,” said Brad Lazernick, Director of The Center for Aging at SSSEVA. “When we can help avoid re-hospitalizations, we’re not just saving money. We’re also fulfilling our mission of helping seniors live with choice and dignity in their community, and with a much higher quality of life.”
With an E3 Grant, SSSEVA, an Area Agency on Aging, created its Hampton Roads Care Transitions Project to reduce preventable hospital readmissions and medication issues for patients with multiple chronic diseases, including congestive heart failure, stroke, diabetes, chronic obstructive pulmonary disease and others.
The program is highly collaborative, relying on referrals from the Care Coordination staff at Sentara Norfolk General Hospital, Sentara Leigh Hospital and Southampton Memorial Hospital, and the input of faculty and students from the nearby Hampton University School of Pharmacy.
SSSEVA’s social workers and RNs serve as Transition Coaches® certified through the Care Transitions Program®, which focuses on engaging seniors and/or their caregivers in self-care. The Transition Coaches are part of a transition team that also includes the hospital’s Care Coordination staff and fourth-year pharmacy students supervised by a licensed pharmacist at the pharmacy school. Transition Coaches visit with seniors in the hospital and then provides follow-up with one home visit and three phone calls over 30 days post-discharge.
“This is an empowerment model,” Lazernick said. “Our seniors learn that, with support, they can manage many aspects of self-care—and they can stay safely at home.”
Hampton Roads Care Transitions Project uses HomeMeds®, a computer-based medication management system that screens older clients’ medications and alerts the pharmacy students and consulting pharmacist about any potential medication errors and/or adverse effects. The pharmacists provide education and advice to the patients, their caregivers and the Transition Coach.
In its first year, Hampton Roads served 114 seniors. For these patients, the 30-day hospital readmission rate was 6 percent, compared to the baseline rate of 19.6 percent for patients with similar diagnoses who were not part of the program. SSSEVA estimates that the program helped 15 seniors avoid hospital readmissions, saving 94 hospital days and $120,000, Lazernick said.
In early 2015, the Hampton Roads project was named one of six national Hartford Change AGEnts Action Award winners for achieving meaningful change in practice to improve the health and wellbeing of older adults. The award came with a grant to help support the continuation of the program.
Today, the program serves about 350 seniors each year, Lazernick said. Earlier this year, the Cardinal Health Foundation awarded SSSEVA a new, multi-year E3 Grant to continue expanding the program. With the grant, SSSEVA will also pilot the use of VSee Telemedicine, a HIPAA-compliant telehealth system that will allow real-time conversations among senior, Transition Coach and pharmacist, while the coach is in the senior’s home.