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CKHS and COSA Receive Grant for Transitional Senior Care

In Brief

  • Crozer-Keystone Health System and the County Office of Services for the Aging received a two-year, $400,000 grant from the U.S. Department of Aging’s Administration on Aging (AOA) and The Centers for Medicare and Medicaid Services.
  • The grant is one of 16 awarded nationwide.
  • It will be used to pilot a program at Taylor Hospital for patients aged 65 years and older who meet specific medical and psychosocial criteria. The program will help identify patients’ needs and coordinate their post-hospital care services before they are discharged, then monitor the patient for two or three months after discharge.

Crozer-Keystone Health System (CKHS) and the County Office of Services for the Aging (COSA) received a two-year, $400,000 grant from the U.S. Department of Aging’s Administration on Aging (AOA) and the Centers for Medicare and Medicaid Services.  

The grant, which the Pennsylvania Department of Aging applied for on the behalf of CKHS and COSA, is one of 16 awarded nationwide. It will be used to pilot a program at Taylor Hospital for patients aged 65 years and older who meet specific medical and psychosocial criteria. 

“The relationship between hospitals and their Area Agencies on Aging should be closely linked,” says Barbara Alexis Looby, administrative director of Senior Health Services for CKHS. “Here in Delaware County, this grant affords both our health system and COSA the opportunity to collectively address the needs of our mutual patients. We recognize that caring for older adults requires a unique skill set that extends beyond the clinical care we offer in our acute care hospitals.  

“Bridging the gap between inpatient and outpatient services provides a smooth transition for our patients,” Looby says. “Our team, which consists of an Advance Practice Nurse and a COSA assessor, screens hospital inpatients who have a certain set of risk factors. We identify their needs and coordinate their post-hospital care services, all occurring prior to discharge. Our coordination includes needed medical services, such as home care and post-discharge physician appointments, as well as in-home community-based services that are coordinated through COSA. Our hope is that this type of care coordination initiative will reduce hospital readmissions among these patients.”  

The program is built from a patient-care management trial that Looby initiated at Taylor approximately one year ago. The program is now based on the well-known and regarded Transitional Care Model (TCM). It requires the services of a dedicated full-time Advanced Practice Nurse (APN). In addition to the age-specific and medical criteria, patients must be alert and oriented, reside in Delaware County, and be reachable by telephone post-discharge. 

The screening process begins between 24 to 48 hours after the patient arrives at the hospital, with continual monitoring throughout their stay. The APN and a COSA assessor, who are both based at Taylor, will work with hospital staff (such as physicians, nurses, social workers, case managers and others) as well as the patient’s primary care physician and family to identify services that will be needed once the patient goes home. The goal is for the patient to have their first nursing visit within 24 hours after discharge, and an appointment with their primary care physician within three days.  

By conducting home visits and making daily, then weekly phone calls, the APN will monitor the patient for two to three months after discharge to make sure he or she is getting the necessary medical care and is complying with instructions for follow-up care (such as keeping doctor appointments and taking medication). She will also ensure that the patient is receiving the appropriate community-based services and in-home services such as personal care, phone monitoring, home- delivered meals, wound care healing and linking individuals with transportation opportunities. 

“Once at home, the COSA assessor transfers his/or her responsibility of the patient to a COSA social worker creating a continuity of care and care coordination throughout the intervention, said Louis Colbert, director of the Delaware County Office of Services for the Aging.  “Community-based services are matched to the patient’s individual goals as needed. These supports help to reduce the stress of the recovering older adults and their caregivers. Weekly visits and telephone outreach will also continue throughout the intervention.” 

The program officially kicked off at Taylor in February 2011. The goal is to expand services so that others in our community can take advantage of everything the program has to offer. Over the two-year period, CKHS and COSA will follow a minimum of 235 individuals. 

“This truly is an exciting project,” Looby says. “When COSA and Crozer-Keystone conducted our pilot one year ago, we were able to assist 213 older adults, and referred 115 of those patients to COSA for assistance. Receiving this grant is indeed a testament to the work we do every day at Crozer-Keystone and COSA. The Pennsylvania Department of Aging saw value in our program, and offered to include us in its grant application to CMS and AoA. We are excited to be involved in one of only 16 grants in the country. Crozer-Keystone and COSA have enjoyed a long, fruitful partnership over many years, and I am honored to be a part of such a groundbreaking initiative.” 

Crozer-Keystone’s Senior Health Services Department is a team of professionals dedicated to assisting seniors, their physicians, family and caregivers in accessing the quality programs and services offered throughout the health system and the community. For more information about the programs provided through Senior Health Services, call 1-800-CKHS-KEY (1-800-254-7539) or visit www.crozer.org. Crozer-Keystone Health System is the largest provider of healthcare services in Delaware County. 

The Delaware County Office of Services for the Aging (COSA) provides leadership, services and advocacy to promote the dignity, independence and quality of life for seniors, adults with disabilities and their caregivers. For information about available resources and/or referrals to particular service programs or agencies call COSA at (610) 490-1300 or visit our website at www.delcosa.org.

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