Care Transitions Achieving Better Health Outcomes

Project Term: 24 months; Ended 2018
Grant Amount: $135,250

This project supported a care coordination position to help older adults transition successfully from the hospital back into their homes. This group of patients tends to utilize high-cost services such as inpatient care more frequently than the general population, and social risk factors such as poor housing and social isolation often lead to poor clinical outcomes. The project used an established model that involves home visiting followed by frequent phone or in-person contacts during the month after a hospital stay. The program also identified social risks and helped coordinate appropriate referrals as needed. Missoula Aging Services successfully developed data sharing agreements with the local hospital and other partners to ensure the discharge needs of the patients were met. The program saw a dramatic decrease in readmissions for this senior population and an increase in discharge instructions and care recommendations among patients. Funding from local partners and potentially the local hospital will help continue these care transition efforts.

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