Helping seniors stay home from the hospital: Gwen's story

Care Transitions Client
Gwen, a Care Transitions client, at home after a hospital stay.

The day Gwendolyn met Pat, she was, as she put it, “in a mood.” Newly discharged from the hospital following life-saving surgery on her neck, she was growing weary after visits from health professionals. Now, here was Pat – yet one more visitor asking questions.

As Gwen discovered though, Pat’s visit was different.

“I told her the medications I was taking were making me feel confused,” said Gwen, a 69-
year-old former nurse. “It scared me. I wasn’t sure what I should be taking and what I shouldn’t be taking. Pat sat down beside me, took my hand, and told me she would walk me through everything. She didn’t rush. She made me feel like I was the most important person in the world.”

Pat is a COA Care Transitions health coach. She helps at-risk patients avoid re-admission to the hospital with a set of proven interventions, such as help with understanding and adhering to discharge instructions. Coaches meet with patients within 72 hours of their discharge and follow up with three phone calls within a 30-day period.

Gwen and Pat
Gwen with her Care Transitions health coach, Pat

Gwen, who had been in and out of the hospital several times over the past two years, showed Pat two dozen different bottles of pills for a variety of health problems. Comparing them with Gwen’s discharge summary, Pat discovered four medications were missing. She called the home health agency that had been assigned to Gwen by the hospital and a nurse placed an order for the missing medications. Pat also gave Gwen a Personal Health Record booklet which she uses to track appointments and list medications and questions for her doctors.

“I feel good about helping her,” Pat said. “I really feel I have found my niche.”

“The thing I can’t stress enough is, when a senior is coming home from the hospital or a nursing home, to have that extra safety net there is so important,” Gwen said. “You’re still feeling a little out of synch – not lost – but a little needy. I’m here because Medicare wants to make sure I’m OK and not going to turn around and go right back into the hospital.”

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