DURHAM, NC – A Medicare report revealed that one in five hospitalized patients age 65 or older suffering from heart failure, heart attacks or pneumonia returns to the hospital within a month to receive care. Most of the time the reason for the return is the patient’s multiple co-morbidities, complex medication regiments or frailty, which complicates the transition from the hospital to home.

Reduce readmissions of our veterans

Knowing this information, Cristina Hendrix and an interprofessional team developed the Transitional Care (TLC) Partners program at the Durham VA Medical Center in North Carolina. Staffed by nurse practitioners, social workers, occupational therapists and a physician, the program works with older veterans and their caregivers to reduce the rates of readmissions, emergency department visits or admittance into a nursing home.

Complex regimen for home care

“When a patient has to continue with a complex regiment at home, it can be a bit daunting for them and their caregivers,” says Hendrix, associate professor at Duke University School of Nursing and TLC Partners program lead. “We wanted to develop a program that would allow these patients an opportunity to comfortably recover in their own home, as well as provide support to the caregiver that would decrease uncoordinated or fragmented care.”

Home recovery

TLC Partners is based on Dr. Mary Naylor’s Transitional Care Model, which addresses the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute care setting to their home or other care setting. With TLC Partners, before a patient is discharged from the hospital a nurse practitioner meets with both the patient and the caregiver and provides health education such as medication management and symptom management. They also provide training of skills for at-home care such as proper use of home oxygen.

Source:

http://today.duke.edu/2015/11/vetcare

Holistic Caregivers for homebound seniors 408-854-1883 motherhealth@gmail.com