According to the Senior Housing News blog called Senior Rehospitalizations Hinge Directly on Location, a Robert Wood Johnson report found that ‘discharge management with follow-up, patient coaching, disease/health management, and provision of telehealth services are among interventions shown to have positive benefits on readmission rates.’
As Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation notes in the reports introduction: ‘Getting people the care they need outside of the hospital is imperative.’
Lifesprk’s model, especially with its Life Care Management services, is uniquely able to help you close the loop in the community:
- Personal consistent involvement with a caring professional: Lifesprk assigns a dedicated Life Care Manager (registered nurse) to every client to become their trusted advisor, providing ongoing proactive support and attention to small changes before they become big crises. Private-pay services for caregiving do not include this level of proactive oversight. We have repeatedly heard from all types of health care professionals that THE BIGGEST GAP and risk for readmission is that there is no ongoing connectivity with people in the community. Lifesprk’s model was deliberately designed to offer that essential connectivity.
- Health coaching: Life Care Managers (LCM) invest time on a regular basis with clients, getting to know them and what is important to them. As a result, they play a significant role in helping clients to identify goals, developing a plan and coaching clients on a consistent basis toward their goals.
- Medication management: As RNs, LCMs provide the medication management and oversight of any delegated caregivers assisting with medications for clients. When clients are discharged home with Lifesprk LCM services, you can rest assured that medication teaching, set-up, coordination and ongoing support will be provided.
- Follow-up and coordination with physicians: LCMs can not only
accompany clients to physician appointments, they can also play a critical role in ensuring the physician orders are understood and followed by the client. LCMs can coordinate the physician and medical care with clients’ families as well, ensuring everyone knows the plan. LCMs play another role as well – they can be the physician’s eyes and ears in the client’s home. LCMs get to really know clients and their routines and health status.As a result, they can help physicians make the best use of the short time they often spend with patients. By sharing their knowledge of the client and helping the physician to understand the unique client needs, LCMs can actually help prevent misdiagnoses and diagnostic errors. According to a Modern Healthcare article, Diagnostic Errors Common in Primary Care, ‘most process breakdowns were related to the clinical encounter, wherein practitioners are almost always pressed for time to make decisions.’ Those breakdowns were at the root of many of the errors common in primary care and cited in the Journal of American Medical Association study.
- Client engagement: Through the Lifesprk ExperienceTM LCMs start with the client’s goals first, engaging the clients in what is most important to them, and then build the Life Plan around those goals, addressing whatever may interfere. As a result, clients are engaged from the start.
- Attention to psycho-social needs: Using a holistic approach, LCMs address all 7 elements of living well, and help clients examine needs or issues related to all aspects of their lives, including social support, isolation and loneliness which can have risks as serious as physical health issues. Few other providers are addressing these broad-spectrum needs or have interventions to affect psycho-social issues.
- Keep clients connected – to their community, physicians, health care providers: According to 6 Lessons for Reducing Readmissions, keeping connected with clients is one of the most important things you can do. While many providers have care transitions, Medical Homes and other new services in place to stay connected to clients immediately after a hospitalization, few continue that connectivity for longer than 30 days. And almost none address all 7 elements of living well, helping clients stay connected to their church, their family, their local community, and anyone else important in their lives. Lifesprk provides this connectivity at each of its service levels. In fact, Lifesprk Connect, a free program, is designed to provide proactive connectivity twice a year to people and offers 24/7 access to Lifesprk’s Navigation services for any resource they need.
These are just a few of the tasks and responsibilities that Lifesprk LCMs can assist with. Find out more about Lifesprk’s services, or request a free Life Consult for a client today, by contacting Lifesprk Navigation at 952-345-8770 or email us.