Caroline Ryan, MA (SW) Aging Care Connections Thank you to The Practice Change Fellows Program, The Atlantic Philanthropies and The John A. Hartford Foundation Safe Discharge Home: A Community Response to Rapid Reintegration of Observation Patients

 The number of patients classified under “observation status” in Illinois hospitals has increased 900% over the past ten years  The existing aging service system is not well equipped to respond to the immediate needs of observation patients post-discharge  Safe Discharge Home improves the ability of the community to rapidly respond to the needs of observation patients as they transition from hospital to home

 Aging Care Connections ◦ Non-profit social service organization ◦ Designated as a Care Coordination Unit and Elder Abuse Unit by the State of Illinois  Adventist La Grange Memorial Hospital ◦ 223 bed community hospital in La Grange, IL

 Community Response Network Requirements ◦ Licensed service providers ◦ Capacity and willingness to expedite services ◦ MOU

 Type of Service Providers ◦ 14 Private Homemaker Service Providers ◦ 5 State Contracted Respite Providers ◦ 4 Pharmacies that deliver ◦ 3 Home Visit Physician Organizations ◦ 3 Home Hair Care Agencies ◦ 3 Private Meal Providers ◦ 2 Volunteer Organizations ◦ 2 Medicaid Waiver Providers ◦ 1 Adult Day Care Center ◦ 1 Durable Medical Equipment Lending Closet

 76% over the age of 75  44% living alone  96% unmet psychosocial needs  92% frail  80% at risk for nursing home placement  79% eligible for state subsidized services

 Reduced length of stay  Reduced number of Emergency Room visits and hospital readmissions within 48 hours and 30 days of discharge  Reduced time between discharge and start of community services  Increased patient and caregiver satisfaction

 September 2009 – May 2010 ◦ Program protocols and evaluation methodology developed with ALMH and IRB approval obtained ◦ Aging Care Connections staff trained to coordinate transitions for observation patients in Safe Discharge Home ◦ Community Response Network formed and referral system developed  June 2010 – July 2011 ◦ Safe Discharge Home implemented at ALMH ◦ Ongoing Community Response Network Meetings ◦ Monthly measurement of patient and caregiver satisfaction ◦ Quarterly collection of readmission and length of stay data  August 2011 ◦ Report summarizing program results submitted to ALMH and the Illinois Department on Aging ◦ Successful components integrated into Aging Resource Center Program and presented to Illinois Transitional Care Consortium

 Private/Public Partnership ◦ Hospital Savings  Reducing length of stay through Safe Discharge Home could save the hospital approximately $300,000 per year  Reduced ER visits  Reduced readmissions within 30 days ◦ Community Contribution  Funding through billable assessments

 Nurse case managers charged with monitoring the status of all observation patients at the hospital were originally going to serve as the referral source ◦ The hospital social workers also want control of program referrals  Clinical judgment vs. risk criteria?