Experimental program helps hospital patients get home quickly

Tuesday, October 18, 2016

Fast Track Home client
After he was discharged from the hospital, Larry was able to by-pass a nursing home stay thanks to Fast Track Home. 

A fall in the shower was Larry’s alarm bell that all was not right with his health. Two days later, he could not get out of bed and called 911. At Clinton Memorial Hospital, he was diagnosed with a urinary tract infection and dehydration.

Larry, a 73-year-old retired railroad engineer, was anxious to get home once he began to feel better. He missed the workroom in the garage behind his home where he spends most of his time tinkering and woodworking. Like many older hospital patients, though, he needed to make some changes at home to accommodate his health problems and to help him avoid future emergency runs.

Unfortunately, hospital discharges usually can’t wait the weeks it may take to set up in-home care services. So, before they can return home, many patients take a detour to a nursing facility for care and rehabilitation.

Council on Aging (COA) has long wanted to find a way to shortcut this process so in-home care services would be ready and waiting for patients when they discharged from the hospital. With support immediately available at home, patients could avoid costly nursing home placement as well as a quick return to the hospital, which often happens when a patient isn’t ready to care for himself without help.

This summer, with the support of Clinton County Commissioners, COA launched a small pilot program at Clinton Memorial Hospital called Fast Track Home. COA’s Care Transitions coach, who is based at the hospital, identifies patients who are candidates for in-home care services and then contacts care managers for the Clinton County Elderly Services Program for follow up.

Fast Track Home changes the normal eligibility process for the Elderly Services Program, which typically takes two to three weeks, and allows in-home services to be set up immediately, on a temporary basis.

When the coach met with Larry, he was enthusiastic about receiving services to help him at home. He lives alone with little family support readily available, is unsteady on his feet, and has diabetes, which requires special attention to his diet.

After a few days in the hospital Larry returned home with three basic but essential services already in place: housekeeping help, home-delivered meals, and an emergency response device. He understood that the services were temporary and that he would have to undergo a full assessment to determine ongoing eligibility.

After Larry had been on Fast Track Home for 40 days, his COA care manager, Karisa, conducted a full assessment at his home and determined that he was eligible for ongoing services. The assessment included verification of his income (to determine co-payment) and a clinical evaluation of his functional capacity and needs. Larry kept the emergency response device and the housekeeping help and switched to home-delivered meals for people with diabetes. He will continue to have regular contact with his care manager for as long as he is on the program.

“I really appreciate all the help,” Larry said. “It’s been awesome. I’m by myself. My kids don’t live close, but I moved out here because I like the quiet. I’m not a city person. I do have some pain – my back and everything – and my balance isn’t good, but you can’t just quit. Some people just give up, but I’m not about to do that.”

Fast Track Home is very small for now and operates only at Clinton Memorial Hospital. Initial screenings may also be done at nursing homes in Clinton County. As of September, 17 seniors had been enrolled in the Clinton County Elderly Services Program prior to discharge from the hospital. After the temporary service period ended (60-day maximum), three of them transitioned onto the program for ongoing services. Of those who disenrolled, the average length-of-stay on the program was 35 days, enough benefit to ease their recovery and help prevent a quick revolving door back into the hospital.

“We hope to expand into Hamilton County,” said COA’s Vice-President of Program Operations, Ken Wilson. “In November, we plan to make a proposal to county commissioners for approval. The Elderly Services Program already does a good job helping older people avoid nursing home placements and hospital readmissions, but it can be even more effective if we can start services immediately, when they are needed most.”