After a successful pilot launch in Clinton County in 2016, Council on Aging (COA) expanded its Fast Track Home program this year to three hospitals in Hamilton County: Christ Hospital, University of Cincinnati Medical Center and The Jewish Hospital – Mercy Health.
It’s not unusual for seniors who no longer need to be in the hospital to be discharged before they are able to fully care for themselves at home without support. Medicare does not pay for meals, help with bathing or transportation to the doctor. Sometimes in these situations, a nursing home stay in between is the only option. And sometimes those who do go home without support end up being readmitted to the hospital.
Fast Track Home strives to help seniors avoid both situations. Through the Hamilton County Elderly Services Program (ESP), Fast Track Home provides immediate in-home support to eligible seniors who are being discharged from the hospital. A change in ESP’s traditional enrollment process eliminates the typical ESP eligibility review process of two to three weeks, and allows in-home services to be set up within 24 to 72 hours.
“This program closes the gap for seniors who may not traditionally qualify for long term services and supports and it allows them to receive the services when they need them the most,” said Forrest Pettit, Elderly Services Program Manager.
COA coaches based at each hospital identify patients who are candidates for the services and then contact ESP care managers, who work with the patient and their healthcare team to set up ESP services such as homemaking, home-delivered meals, medical transportation and care management.
All services are provided free of charge for up to 60 days. The care manager continually monitors the patient’s care and adjusts services as needed to prevent hospital readmission and nursing home placement. Near the end of the 60-day enrollment period, the care manager conducts a full eligibility assessment for the Elderly Services Program.
Since its inception, 320 seniors have enrolled in the program. The current national average for hospital readmission is 17.5 percent. For Fast Track Home patients, the average is closer to 11 percent. Of those enrolled, 47 percent have transitioned to ongoing ESP after the temporary service period ended. Of those who have transitioned to independence, the average length of stay on the program is 39 days, enough benefit to ease their recovery and help prevent a return trip to the hospital or nursing home admission.
“Fast Track Home has been and will continue to be a beneficial program for COA but also and more importantly for individuals in the community,” Pettit said.