PROFILE: Seniors’ Resource Center

Hospital discharge is a vulnerable time for all patients, but even more so for those without transportation or a support network. Lutheran Medical Center (LMC) and the Seniors’ Resource Center (SRC) are working together to ensure that these frequently overlooked individuals make it home safely, securely, and compassionately.

A Perfect Homecoming is a pilot program housed in LMC’s Care Management Department and facilitated by SRC’s transportation services. Carol Mitchell, manager of In Home Care Services at SRC, describes the endeavor as a partnership that “brings a transportation and transitional care model into the home with interactions to improve patient outcomes and satisfaction while reducing emergency department and hospital readmissions.”

Typically, when a patient does not have a way to get home after discharge, the hospital will pay for a taxi. This is costly and does not ensure that the patient gets settled at home safely. A Perfect Homecoming provides “door through door service,” Mitchell explains, “meaning that a driver offers arm-assists to patients in and out of the vehicle and into the home, whereas a cab driver likely will not.” The driver also takes the patient to the pharmacy if necessary and, when requested, can stay with the patient for up to an hour after arriving at their home.

SRC and LMC believe that in-home care by a qualified provider is an important extension of hospital services and that when a patient feels comfortably settled in their house, a readmission is less likely to result. Personal Care Providers are available to assist patients with small tasks such as light housekeeping, errands, or laundry.

A Perfect Homecoming is funded through a grant from the Lutheran Medical Center Foundation and grew out of discussions between LMC’s Care Management Department and SRC regarding patients’ need for a ride home after discharge. SRC is a leader in community-based services and already provides transportation for seniors in Jefferson County, where LMC is located, so the partnership was a natural conclusion to discussions. The first ride was provided in July of 2014 and within months the hospital extended the pilot to all departments beyond Emergency and Internal Medicine and began including patients of any age without a support network.

An important side effect of the program is the human connection between driver and patient. “Drivers who have provided rides to patients report that patients have all expressed gratitude for the service,” notes Mitchell “An unintended benefit for some of the patients has been socialization with the driver.  The drivers say it is not unusual for a patient to invite them in upon arriving home.”

LMC and SRC are helping patients through the difficult transition between hospital and home in a thoughtful and compassionate fashion. Mitchell sums up the key elements of the program’s success. “A ride home with a caring driver, a stop at the pharmacy and in-home care paid for by the hospital and at no cost to the patient, all from an agency that is a leader in community-based services, is an exceptional program.”

Previously published as part of CIVHC’s Spotlight on Innovation series.