DelawareCountyTransitionalCareModel.pptVIP

Delaware County Transitional Care Model “Making it Easier for Individuals to Navigate their Health and Long Term Care though Person Centered Systems of Information, Counseling and Access” * Laying the Foundation AAA - Delaware County Office of Services for the Aging – (COSA) Crozer Keystone Health System (CKHS)– Senior Health Services * COSA AAA in southeastern PA Department of local government 1 in 5 residents are over age 60 Provide traditional AAA services such as senior centers, nutrition services, legal assistance, volunteer opportunities, IR, LTC assessment, Aging Medicaid Waiver, FCSP, PS, Ombudsman, state funded care management * CKHS Operates 5 of the 7 hospitals in the County Operates 4 of the 6 inpatient hospitals in the County Senior Health Services is a department within the Crozer Keystone Health System * Partnership For some time COSA and CKHS – Senior Health Services have worked together in efforts to impact a positive change in the culture between the acute care setting and AAA supported home and community based services * What we Found Perceptions are hard to change The fit was perfect It was the appropriate time We are consistent with the national trend We are able to build on existing programs * Foundation in Place 2006 COSA was designated as a Community Choice County by the PA Dept of Aging 2008 Nursing Home Transition program implemented 2009 grant to develop an ADRC for the County 2010 COSA member of the CKHS Heart Failure Transition Team * 2010 Taylor Hospital Discharge Project All referrals with 4 diagnoses (CHF, MI, COPD, Pneumonia) referred to Senior Health Services by hospital discharge and ER staff Senior Health Services refers to COSA for assessment and services Senior Health Services follows consumers Senior Health Services/COSA Intake – Assessment Program Manager communicate daily * Foundation Laid By working very closely with CKHS The Transitional Care project is building on what we have in place The overriding goal of the projec