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CICOA Care Transitions Provides High Quality of Care, Reduces Health Care Costs

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After Clarissa, 84, fell down the stairs of her home, she was rushed to Methodist Hospital where she was diagnosed with a brain contusion and spent seven days in the Intensive Care Unit. For the next several weeks, however, she remained hospitalized, dealing with secondary health conditions including multiple infections, pneumonia, memory loss and difficulty swallowing and speaking.

Her daughter and primary caregiver, Gladys, worried about how she would care for her mother at home and diligently observed the hospital staff at work. She learned to crush the medications into applesauce so her mother could swallow them and how to help with physical therapy exercises. Fortunately, she also met Lisa Santangelo, the CICOA Aging & In-Home Solutions’ care options counselor at Methodist, who stopped by Clarissa’s room to assess what her needs would be following the hospital stay.

Santangelo is part of CICOA’s Care Transitions team. Options counselors at Methodist Hospital and Eskenazi Health work with the Geriatric Resources for Assessment and Care of Elders (GRACE) team to provide support during an individual’s transition from hospital to home or to another care setting. Using the GRACE model, the staff consider an older patient’s health status and support structure and then connect individuals to available community resources that can help them reduce healthcare costs and hospital readmission rates while continuing a high quality of care.

According to Paul Watkins, CICOA’s director of health care collaboration, options counselors completed 568 referrals or consultations with health care professionals from July 2012 to the end of June 2013. Options counselors have linked individuals to more than $2.1 million in community resources, Watkins said, diverting $2.9 million from skilled nursing facilities or hospitals and saving almost $800,000 in health care costs.

“Options counselors have their pulse on community resources,” Watkins explained. “They help individuals identify what resources are available, which providers offer needed services, and the eligibility requirements for different home and community-based services. Individuals can then sign up to receive the identified services, if they qualify.”

Clients receive extensive follow up after hospital discharge, including:

  • Home visits, starting two to three weeks after discharge.
  • A comprehensive in-home geriatric assessment by a nurse practitioner or social worker one, two, three, six and nine months after discharge.
  • Targeted assessments on issues related to dementia, fall risk, depression, nutrition, social support, transportation needs and home- and community-based services.
  • Follow up reports to a multi-disciplinary team that might include a physical therapist, nutritionist, physician and other healthcare professionals.
  • Monthly phone calls or in-home visits by a nurse practitioner or social worker.

The options counselors provide information and referral to clients and educate caregivers about various services, including attendant care, transportation, durable medical equipment and home- delivered meals.

“Using these services allows a person to live as independently as they can, for as long as they can,” Watkins said.

Clarissa has been home from the hospital for three weeks, and support services are now in place to help her remain there safely. Santangelo helped the family find a hospital bed and a wheelchair. A social worker from Bethany Home Care Services provided a home assessment. A nurse visits twice a week, and a nurse’s aide provides assistance two hours a day, three times a week.

Her relieved daughter and caregiver, Gladys, said, “My mother is starting to recover her memory and she is eating and talking more. I am doing the physical therapy exercises with her, and we are hopeful she may be able to walk again.”


CICOA Aging & In-Home Solutions is the premier source of information and access to resources for older adults, people of any age with a disability and family caregivers living in Central Indiana. Through a network of agencies, service groups and volunteers, CICOA provides home care services, home-delivered and neighborhood meals, home health care, transportation services, home modifications, respite care and caregiver assistance. Annually, CICOA’s Aging & Disability Resource Center handles more than 100,000 calls from people seeking assistance with aging and disability issues. CICOA is Indiana’s largest Area Agency on Aging and serves Boone, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, and Shelby Counties, where more than 26 percent of the population lives. To learn more about CICOA visit

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