The Care Transition Nurse will work with Jefferson House staff and patients to complete a discharge preparation checklist. The patients, with the help of the Care Transition Nurse, will complete a personal health record with specific goals to help them self-manage their health. After discharge to home, the nurse will then follow up with an assessment of individual needs, which include reconciling medications and safety evaluation. In-home visits and telephone support will be provided as needed. Patients are being provided an extensive array of resources to enhance their move from the facility to their home, thus easing the strain on them and their caregivers. These services range from an emergency response system to transportation to physician appointments.
“It is refreshing to have a new clinical program that is based on preventing something from happening, as opposed to reacting after the fact. This is redefining how we approach patient care,” states Ellen Rothberg, President and CEO of VNA HealthCare. “We are actually beginning to see meaningful change in care delivery and health care providers are challenged to identify new ways of delivering care to ensure increasingly better patient outcomes and satisfaction.”
Alan Laites, Executive Director of Jefferson House and an enthusiastic proponent of innovations in geriatric care, states, “The successful implementation of this project will not only improve the quality of care provided to the patients discharged, but will also fundamentally change how we think of discharge planning. We’re touching a population who doesn’t normally get post-discharge services. I’m thrilled we were able to work together with VNA HealthCare and fund this project.”
Care Transition Programs have been researched, implemented and evaluated for effectiveness across the country, most notably at the University of Colorado ( the Coleman Model) and the University of Pennsylvania. The Centers for Medicare and Medicaid are actually funding test models of Community Based Care Transition Programs from acute care settings in order to improve quality of care, reduce high risk readmissions and document cost savings to the Medicare Program.
About VNA HealthCare
Founded in 1901, VNA HealthCare provides home health care to more than 60 towns in Central Connecticut and Greater Waterbury. The agency provides care ranging from skilled nursing, hospice, rehabilitation and speech therapy to advanced cardiac nursing, Lifeline and personal care. VNA HealthCare is a Hartford HealthCare partner and is a Caring Partner with Saint Mary’s Hospital. VNA HealthCare employs more than 800 employees and cares for more than 17,000 patients annually. www.vnahealthcare.org
About Jefferson House
Jefferson House was the first Nursing Home in Connecticut and began operations in 1884 as a Department of Hartford Hospital. Originally called the Old Peoples Home, the facility was a new four story building located on Jefferson Street across from the Hospital. The name was changed to Jefferson House in 1953 and after 96 years in various locations at the Hospital, in 1980 Jefferson House moved to a new state-of-the-