As a nurse with more than 24 years of experience in health and transitional care, Lyn Lais, RN, has seen far too many people riding the roller coaster of health care crises until their health is severely compromised. While Medicare has sought to spur innovation and change through both penalties and pilots, those efforts don’t go far enough.
Lyn, who works as a Life Care Navigator, has been spearheading Thrive On @ Home, a collaboration between Lifesprk and Augustana Care in the Twin Cities market that is seeking to go further in reducing readmissions so many seniors face by creating a long-term solution.
Writing in a blog on McKnight’s Long Term Care News, Lyn urges health care providers to “look at the whole person’s needs to help people recover and live fully” at home. As health care reimbursement focuses primarily on acute health care needs, providers mirror that narrow scope. And yet, as Lyn has found, many, many factors play a role in a person’s risk of being on that roller coaster of crises – social support, home and safety, finances, identity, feelings of purpose and passion, thinking and memory, in addition to health concerns.
At the same time, too often transitional care efforts are short-term, which creates gaps in care and support where people can relapse or minor issues can grow into major concerns. “Thirty days, or even 90 days, are not long enough. Through the years, I have seen the difference that a long-term approach makes, eliminating those gaps where people often fail,” adds Lyn.
So what is needed to help seniors thrive at home? The Thrive On @ Home program provides:
- Free phone support available for the long-term
- Educational tips
- Connections to resources
- Follow-up calls and visits made periodically after discharge
- Check in calls every six months after program participants are discharged
- A quarterly newsletter and email tips sent to participants
“It has been exciting to work with both Lifesprk and Augustana Care,” Lyn said. “They each bring different strengths and capabilities to the effort to help people live their lives with passion and spark at home. We found that people really don’t want care once they are discharged from a transitional care unit; they want to thrive and live life on their own terms. This program has been designed to help them do just that – providing the right level of support at the right time, and working to ensure that little issues are addressed before they become major crises and land people back in the hospital.”
She stresses that understanding and focusing on the whole person will provide the insights and keys to successfully enabling them to get off that roller coaster of crises.