By Ashley Washington, Director, Aging Initiatives
In late April, Connect-Home Collaborative members from Lutheran SeniorLife in Pittsburgh, Niagara Lutheran Health System in Buffalo, New York, and Luther Manor in Milwaukee, convened virtually to discuss their year-end findings participating in the Connect-Home model. Developed by Dr. Mark Toles at the University of North-Carolina, Connect-Home is an evidence-based transitional care process that empowers patients and their caregivers to manage patients’ serious illnesses at home, improve function, and prevent avoidable re-hospitalizations. These Connect-Home Collaborative members were previously trained at Lutheran Services in America’s Washington, D.C., office in October 2019 and continued to receive quarterly check-ins and in-person technical assistance from Dr. Toles. During this final virtual convening, members shared their key successes and challenges regarding their implementation of the Connect-Home model.
All members praised Connect-Home’s success in improving their teams’ collaboration efforts in safely discharging patients. Members professed this model helped emphasize the need for comprehensive conversations during care conferences with patients and caregivers to understand what to expect and what is needed during the transition to home. Members also shared this experience helped their staff shift their mindset to not only thinking about the patient's time at the facility, but also envisioning the patient's life at home and how to make patients and caregivers feel empowered and comfortable with this transition.
Connect-Home members also discussed the numerous unanticipated challenges stemming from the current COVID-19 pandemic and the pivotal role of this model during this difficult time. One challenge includes the facilities no longer permitting visitors, including at the time of discharge. Connect-Home members needed to deliver care conferences discussing a patient's upcoming transition to home on virtual platforms instead of in-person. Members cited that the Connect-Home's model ensured that these care conferences and the ensuring discharge summary/instructions were incredibly helpful for caregivers who have not been able to visit their loved ones and see their mobility progress in-person. Other challenges have included the need to ensure patients have plans to secure food, medication, & home care complying with COVID-19 stay-at-home orders. Overall, COVID-19 has been a rallying time for Connect-Home members and their staff to come together to ensure patients and caregivers feel reassured during their time inside the facilities and when approaching discharge.