Lutheran Homes Society introduces 'no walls' Care Transitions program PDF Print E-mail
Written by Sentinel-Tribune Staff   
Friday, 15 March 2013 09:14
Lutheran Homes Society has introduced a new program called LHS Care Transitions designed to help individuals transition back to a home-based setting after a stay in a hospital, rehabilitation unit or skilled nursing facility. It is part of the organization's long-term care and housing and community services ministries.
Lutheran Homes Society, which serves residents in Wood County, is setting up a service line "without walls."
That means that once an individual enters the LHS system, care will be coordinated for them as long as it is needed. Not only does this program expand services beyond the walls of LHS long-term care and rehab facilities, but it has also been proven to reduce the readmission rate to hospitals.
"Lutheran Homes Society has had great success with the Care Transitions program," said Amanda Schroeder, LHS executive director of home and community based services. Since July 1, 2012, there have been 91 cases opened, and LHS has had a 91 percent success rate at decreasing hospital readmission rates for these individuals.
The Care Transitions program expands discharge planning efforts to offer person-centered care and care coordination in the least restrictive home-based setting.
Coordinators work one-on-one with people from the time they are discharged home, focusing on the specific care needs of each individual. Health and safety concerns and each individual's right to self-determination are key factors considered by the coordinators when they make weekly home visits to clients throughout northwest Ohio.
The program focuses on four primary areas: medication self-management, use of a Personal Health Record to ensure continuity of care, follow-up with primary care physicians and specialists, and recognition of red flags and response options.
Coordinators also organize care services with home health providers, primary care physicians, and other medical professionals listed on discharge plans, as well as family and friends.
The program has no age or income restrictions. Call 1-877-646-4050.

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