As individuals age, they may experience health status changes that sometimes necessitate an admission to a hospital, rehabilitation or skilled nursing facility. Upon discharge from a facility, individuals often need additional support to navigate their care plan and any community services as they return home. For many older adults, it is a comfort to know that assistance is available to help them transition from one care setting to another, with the end goal being that they return home safely and avoid readmission.

Old Colony Elder Services’ (OCES) mission is to support the independence and dignity of older adults and individuals with disabilities by providing essential information and services that promote healthy and safe living. OCES has a Transition Support Program that works with individuals to ensure they have all of the necessary services they need upon discharge from a facility before re-entering the community.

How does it work?

Individuals are often referred for OCES’ Transition Support services by facility social workers, other OCES team members, or family members.

OCES’ Registered Nurses (RN) and Transition Support Advisors meet with an individual and his/her family members at the hospital, rehabilitation or long-term care setting and work with them and facility staff throughout the discharge planning process. The program builds upon existing facility discharge planning and serves as a natural extension to support individuals being successful at each care setting and at home.  A Transition Support Advisor will meet the individual, starting with a hospital visit, a skilled nursing facility and/or rehab visit if applicable, a home visit, and three follow-up calls.

In the process of transition, OCES Transition RNs and Advisors communicate directly with individuals (and their caregiver/family members) to learn about their needs, concerns, and services in place as well as any possible barriers to successful transition and will offer suggestions on how they may be addressed.  The Transition RN or Advisor provides education about in-home supports and community services as well as direct referrals to these resources. For example, individuals are educated on Mass Health Home and Community Based Waivers, home modification loan programs, adaptive equipment, services to meet complex medication management and a wide range of additional community resources.

OCES’ Transition Support Program also provides a tracking service for individuals with existing Home Care service plans who have entered a hospital or other facility. This service consists of making contact with facility social workers to discuss care plans, need for changes in services and maintaining awareness of possible discharge plans.  A patient information network, PatientPing, is linked with the electronic health record systems of facilities and provides OCES’ Transition Team with up-to-date information on an individual’s admissions and discharges.  With this system, the Transition Team is able to inform the Home Care department of admissions so services can be suspended as needed, and it also aids in the prompt notification of discharges eliminating gaps in the reactivation of services.

Actively Engaging Individuals & their Caregivers

Intervention from the Transition Support Program staff can help reduce hospital readmissions by 20- 50 percent, while improving the health and quality of life of patients. These individuals and their caregivers learn medication management skills, how to identify red flags in their care management, planning Primary Care Provider and/or Specialist follow-up appointments, and maintaining a personal health record. Most importantly, individuals become more engaged, activated and empowered in their own self-care management skills.

For more information on the OCES Transition Support Program, contact OCES at 508-584-1561.