Over the last several months, Lifesprk has had numerous dialogues with leaders from health care organizations in the Twin Cities metro, and hospital readmissions are on everyone’s minds. In fact, there is frenzied activity to collaborate, improve transitions, align, and integrate.
They lauded care transitions, medical homes, and care coordination programs. And yet, the health care professionals all felt there was a missing element.
Our question to them: what is needed for seniors, people in the second half of life, to succeed in the community and break the cycle of readmissions?
All of them felt that the current efforts don’t go far enough. Here is what they feel is needed:
- Care coordination in the community that is ongoing (no gaps, and not time-limited)
- A trusted advisor who provides continuity of care and service across settings, including the home
- A focus on the whole person, and not just a single diagnosis or episode of care
- A focus on preventive care versus reactive care
Interestingly, what the health care leaders didn’t realize is that all those elements exist in the community and are part of the Lifesprk model already.
So, how would you answer the question? What is needed for people in the second half of life to succeed in the community, and break the cycle of readmissions?
We want to know. Add a comment below. On Twitter? You can also send us a tweet at @Lifesprk.