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Moving from Hospital to Home with Care Transitions

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In July 2010, Johnnie, then 68, was admitted to Wishard Memorial Hospital with chest pain. She had been in and out of the hospital six times over a period of only 10 months. With multiple medical problems, Johnnie required a great deal of care with medication management, bathing, meal preparation, housekeeping, transportation, etc. Although determined for her to return home, her family felt overwhelmed by the support she would need after leaving the hospital.

While at Wishard Hospital, Johnnie and her family spoke with a CICOA options counselor to determine what community resources were available. Together, they developed a CHOICE plan of care, which included home-delivered meals through CICOA’s Meals and More program, an emergency response system and personal care services.

So far, the program is working for Johnnie. Since being enrolled into the program one year ago, she has not been re-admitted to the hospital.

Johnnie’s story is typical of the CICOA clients who are benefiting from a Care Transitions intervention. Funded through a grant from the Administration on Aging, Care Transitions is a collaborative effort between IU Medical Group, Wishard Health Services, Indianapolis VA Medical Center, and CICOA Aging & In-Home Solutions. The program identifies high-risk clients needing long-term care who are Medicare and Medicaid eligible and links them to medical and social services for the purpose of decreasing nursing home admissions and hospital readmissions.

The goals of the program are to:

  • Integrate care managers into the hospital discharge process so they can provide timely, on-site referral to community-based resources.
  • Support a more complete discharge planning process.
  • Support access to high quality, community based long-term care with a reduction in nursing home admissions.
  • Continue a connection with physicians and health care support to prevent hospital readmission or nursing home admission.

Care Transitions is available at Wishard Hospital, VA Medical Center and Methodist Hospital and is coordinated with Dr. Steven Counsell, director, IU Geriatrics and Mary Elizabeth Mitchell Professor of Geriatrics. Dr. Counsell helped develop and currently coordinates the Geriatric Resources for Assessment and Care of Elders (GRACE) program at Wishard.

The GRACE model utilizes a holistic approach to address the older patient’s health needs. As part of this model, GRACE provides an advanced practice nurse and social worker who work with hospital and primary care physicians to provide a unique, person-centered hospital discharge plan, increasing each patient’s ability to follow through with care and recovery instructions after they leave the hospital. Post-discharge support includes at least one home visit and a monthly follow up by phone.

The Care Transitions program extends the GRACE model by providing support and follow up for one year. CICOA field options counselors work in the hospitals and participate in daily hospital rounds and weekly GRACE team conferences. Once a patient is ready to leave the hospital, CICOA counselors provide key support to patients and their families with information about community resources and long-term care options, and help facilitate access to housing and community-based care.

According to Laura Boyle, CICOA senior vice president of client services, the hospital-based Care Transitions counselors serve a triple role. They start the interaction with the patient in the hospital, working with hospital staff throughout the discharge process. They also serve in the social worker role, which is an integral part of the GRACE model. Finally, they provide case management services through CICOA.

These counselors provide information about various services, including:

  • CHOICE and Medicaid home care services.
  • Personal emergency response system.
  • Adult day care or adult foster care.
  • Home-delivered meals.

Boyle said the new model benefits care recipients, their families, and our communities as a whole. “By providing high-risk, high-need patients with earlier access to community resources, this program saves healthcare dollars,” Boyle said.

Dr. Counsell agreed: “The hospitals and physicians are very excited about our collaboration with CICOA and the added value of community care management and options counseling as components of the GRACE care transition model. Our partnership holds great promise for better coordination of care and smoother transitions from hospital back home, in turn leading to better patient outcomes. We hope that this will be a model for the rest of Indiana toward improving the health of older Hoosiers.”


CICOA Aging & In-Home Solutions is the premier source of information and access to resources for seniors and persons with disabilities living in Central Indiana. Through a network of agencies, service groups and volunteers, CICOA provides home care services including personal home care, home-delivered meals, home health care, senior transportation referrals, respite care and caregiver assistance. Annually CICOA provides in-home care management to more than 3,000 clients, delivers more than 500,000 nutritious meals to homes and neighborhood meal sites, and offers respite care and supplemental services to 3,000 caregivers. CICOA’s Aging & Disability Resource Center handles more than 74,000 calls per year from people seeking assistance with aging and disability issues.

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