the LINK - E166 - Hartford Health Care

the LINK – E166 – Hartford Health Care

welcome to the link this is a program all about linking you with the resources in your community I'm Joanie Sutter on today's program we have Amina Weiland who's here with us and she's here from the Harford Healthcare Center for a healthy aging and we are surprised to learn that this has really been in existence since 2004 and Amina is a Resource Coordinator with the organization but there are so many services that are available to people that they don't know about so Amina can you tell me what a Resource Coordinator does so the Center for healthy aging is what we work with together with we have two Center for healthy aging and we have the resource coordinator program we have the dementia services and we have the transitional care nurses program so the Resource Coordinator is where we reach out to the community for any individuals and they're looking for resources and any support they may need as simple as looking for a new doctor sometimes we hear that a lot doctors retiring I want to look for new doctors where we can find them so we help them to navigate those or they're looking for muse on new services or other options when grocery delivery transportations we can have those resources and help them to navigate so the Center for healthy aging began in 2004 and it began as an initiative from research analysis that was conducted that showed some of the gaps that that maybe were in place can you tell us about that a little bit so a lot of time people when they retire when they go home from rehab program and mostly is insurance pay for it and after that they want to know what other services that can tap into in the community can help them allow to stay home longer and safe so we're reaching out to the community mostly starting insulting to Neriah and working with the town social services and do a lot of partnership in a community to see what is available for individuals or the family and then we know that they have some services like news on wheels and that they have other type of services similar to muse on wheels that were able to let us let our clients know and having those services okay so when we talked about hereford healthcare I said to Amina at the beginning of the program why is this program in existence and who's funding the program and you had shared with me that there was some analysis and research that has been done and what were the findings so the finding is we able to fill in the gaps for those who have been going to the hospital many times and we able to our services able to let them keep them home safely to attending those services that they're missing so for example for a lot of time people just going back to the hospital say for example they live alone and they don't have any support so they don't have the transportation going to see the doctor so we're able to tap in those services or maybe more and to let them to have that opportunity to see the doctors so the goal is to reduce hospitalization or readmission rates and so that's what the whole goal is okay so when they did the research and they got the statistics they looked at it and they said this is really worth it for us to fund this is worth it this program is worth it because this program doesn't cost any money and I couldn't believe that when you told me that this is a free service you don't have to have insurance you don't have to you can even be working with a doctor who's outside the Harford health care which is Hartford Hospital which would include Charlotte Hungerford at the hospital of Central Connecticut in New Britain Bradley in southern 10 which is a Care Center of course Hartford and and there's some others but even if you're not with a doctor in those groups you can still participate because they felt that rehospitalization and it reads were less likely with resources found within the community and that you hook people up with what they need right you in the gaps yes what is missing in that person life are you able to listen to their stories and see what would they not need it right now or even making making a long-term plan for them okay and so it can be as easy as and not necessarily easy but meals on wheels or related services to something much more serious which is the transitional care and we're going to be talking with a transitional nurse in a little bit about that side of the business but you've got ten offices really all over the state of Connecticut so there are five features that you have listed as your community outreach the health screenings so you're going to senior centers and you're telling them about that the the wellness lectures the news magazine choices counseling what is choices counseling choices counseling is a program that's funded by the state and then is through the Agency on Aging so that's five Agency on Aging in Connecticut so they have the funding and then providing the training for individuals like us who want to learn more about Medicare and Medicaid and other related to services like that and providing to the free consultation to seniors when they needed to looking for their Medicare Medicare options so life insurance what is available when the open enrollment season so we're able to give them some non biases information for them to make that right choices and many times your assessments include having the family members you had mentioned maybe you can give us an example of if you go out to someone's home maybe they can have a family member there also with them to get some of this information here the information differently than maybe the patient are the person who wants the services would hear the information and help them make some of those choices so what would an assessment look like so when we visiting a client so we definitely encourage the family members to be there either a daughter or son or any relative that involving that person who care so the conversation will evolving majority is evolving that individuals one the individuals tell it about a story what are the struggles what are their strengths what is available right now what is the financial situation so when we gather those information were able to kind of give them some recommendation and what is available in the community what is the funding is any state program they may be able to tap into it if they have been doing some legal planning financial planning that's very important and then for the caregivers we also want to give them some support some material for them to do some health self-care or if someone have dementia we have a dementia special guide for them to educate themselves about the illnesses and a lot of supporting material that they may have and my goal is I hate helping the family as well because they are one that need more help than the one in that already helped in the system your dementia specialists and you do a lot of work both for pay work and volunteer work on the line of dementia and Alzheimer's what are some of the supports systems that are in place for family members who are caring for someone who's has dementia so we have dementia special as well 3-dimensional is actually in on a team and many of our team members is also certified dementia petitioners so we have the knowledge to guide through them the family particularly looking for what is the safety issues at home when we're doing a home visit that's very important and we give them some guidance to say hey Zastrow floor Ruksana enough ground that we may be able to remove them but what are the things that they can do so we're trying to empower them and then the dementia special is also doing a lot of coaching our goal is to help family and give them the power and tools to enrich themselves right mm-hmm because the buzzwords really are aging at home right and nobody nobody wants to have to go into a convalescing facility not because they're not a good place to be but people want to be home right and you probably hear that every day and so these are the tools that people need and the resources that people need at home and it's it's tough it's like you know you're you're going shopping for things that you need at home if you want to be aging at home and you may not be in the right store so if you contact these folks you can find out all the resources that are available to you or to your loved one and it's a free service yep available to you you don't have to have to participate in anything if you don't want to it's your choice and are there some areas culturally where people maybe don't ask for help as easily as other cultures find that yes particularly I know I grew up in Hong Kong Chinese culture particularly my family I know that it's very hard for them to ask him for help and mostly it's a family oriented community so we're big family lucky we have a big family so everybody can pitch in and help grandma so that is a good story but not everybody have that resources and support so now now it's getting much more about what is dementia for example and the resources are mostly out there now so removing the stigma I think that's important for people to understand about the illnesses and getting those resources that they may need and support I think is important is the emotional support that the caregiver can get and so it's not the kind of thing that I think you have to be afraid of that if you invite someone into your home to look at some of these services that are available that they're gonna discover oh this person shouldn't be living at home I mean I would think that that would be some some fears people say well maybe they're gonna tell me I have to go to the convalescent home and I don't want to so I'm not even gonna have anybody come in probably not the best choice for you because there are so many things many more than in the last 10 years wouldn't you say I mean you started in 2004 with just this program started in 2004 but there are so many things that have changed in a short period of time technology one of the big things that we hear a lot is technology and technology can place a big important part in our life including how can we use technology to stay home longer right and and I think that transitional care and the nursing that goes along with that you know now you now you're talking about the next level which is your medications and you know maybe if there's a difference in you know time goes by maybe there's a difference in how a person is engaging at home and so those kinds of things we're going to talk about next I want to thank you so much for being here and we're going to continue our discussion with a transitional nurse who has a group that travels around the state and we're going to find out what they do and what they can do for you stay with us so what if some of the questions you're asking or asking for your loved one is what do I do next what do I do if my care needs change if my finances cannot cover the care I need what if my house is no longer the best home for me and what if I need extra help at home who's gonna help you navigate those things but this wonderful organization who's with us today the Harford Healthcare Center for healthy aging and we're joined by nicholas Arsenault who is a transitional care nurse and I was asking you before we started recording today about transition and is it transitioned from home to health care facility and you said no it really isn't what do you do as a transitional healthcare nurse so it's a transitional care nurse I work with for I work as one of four nurses in our program currently and what we offer is a one-time free of charge nursing visit to the home and it's at no cost which is a nice perk for most people it's a nice little gift there and we go out to the home and we usually do about a two to three hour home assessment visit which is really quite extensive that we do things from a full physical exhaustion we're assessing the home environment for safety concerns and issues and recommendations and we're spending a real significant amount of time doing full medication reviews going through all of their medications which can include their prescription medications as well as any over-the-counter and supplements that they take at home and we also really do a lot of one-on-one education regarding their health condition or if they are quite healthy and are fortunate not to have significant health issues we can really help with a lot of proactive health education and how to help them plan for the future with their healthcare needs and help to identify what issues they have and meeting their health care goals that they and their health care providers have set forth for them okay so is it the kind of thing and I'm just going to ask this is it the kind of thing where I come in for you know an hour or maybe two or three hours to meet with you know the one time assessment and then is it well we got it you have to pay for this this this this it's not that at all it's that you come in and all the services are then available for free to that individual or are some free and some would be a cost that's a great question a lot of times our initial visit is like I said free of charge and during the course of the visit when we're having our conversations with you know the patient or the family member or a caregiver in what other caregivers are involved in that situation we're really discussing what resources and services might be available for them and it's really tailored to what their needs specifically are so services that we might recommend for one person today may not be the same recommendations we have for someone that we're seeing the next day in the community and oftentimes we're evaluating for things like if they might qualify for traditional homecare services which would be having nursing services or a physical therapy social work those types of services coming out from a homecare agency or a visiting nurse agency to come out on a more regular basis after our initial visit when they would help to be able to provide ongoing education to pick up kind of where we're leaving off with the education and support and in our evaluation we're determining if they are eligible for those services because if they're eligible for home care those often will be covered under their insurance like Medicare or their private insurance or Medicaid however we do have instances where someone might not meet homecare criteria meaning they're not able to get those services right now in the home which at that point we're not leaving them high and dry we still follow them for 30 days total after sometimes we have folks will follow for an additional period of time if a nursing judgment shows that they need some additional support for a little longer period and we're doing that telephonically however a large part of our assessments also really stem around a psychosocial in social issues they may have in the home because we're looking at the big picture because we find a lot of times there may be issues such as finances limited finances especially they may not necessarily be safe to stay at home by themselves any longer if they have really advanced dementia or something like that so we're really helping to identify if they qualify for other resources in the community at large and some of those services may be programs that they qualify for through the state and that's oftentimes where we may pull in our resource coordinators with our Center for healthy aging to help with that process and take it to the next level with them other times there may be some private pay options that they may be capable of supporting and we'll definitely work with them to identify whether it's a caregiver to come into home is it connecting them with a home modification company to help modify the home so they can age safely in place at home so they can meet their goal of staying there and sometimes it might be some people have the goal of moving to a different location meaning an assisted living facility or a smaller apartment to downsize and that's when we're tapping into our resources to help them identify what's going to be the best fit for them and that's really all networking and so why do that yourself when you can easily work with an agency like yours who has this network all around you you know who's who who's where and how to best get things done and so working through an agency I think and sometimes have things happen a little bit faster too then if you're just calling up on your own and and well I'm not really sure about this or what should I do about this when you could even act as an advocate and do you do that you know if someone needed to say well gee could Nicholas you know be on the phone with me and talk about some of the things that he's observed with me and you know ways that another agency could help correct so it's the transitional care nurse we're really helping to facilitate those conversations if someone that we're doing a visit on has four different healthcare providers with four different medical needs and health issues we're really taking that time to sit down and make those phone calls and connections with each of those providers to help promote that communication amongst all of them so everyone can be on the same page and like you said we have the resources within the Center for healthy aging that we have all of our centers throughout the state that we always have resources at our fingertips to contact someone to help identify those resources whether it be for the care needs like you're mentioning sometimes it's as simple as helping connect someone to one of our hartford healthcare partner services they say get like an automated medication tower system to help manage automated medication dispensing to utilize some technology in the home in order to increase their ability to self manage their medications at home so it really like I had mentioned tailors to each person and the best part is is being a free service any healthcare provider that they're seeing in the community currently whether it be a doctor a nurse practitioner or a physician assistant can sign off on the orders for us nurses to go out and see them so you were telling me that there's a staff of nurses who cover the whole state and so when a call comes in then it goes through a series of different checks and balances and then somebody goes out so is that the first step is the phone call and then the second step is you'd be visited by a nurse or would you be visited by a resource coordinator so usually one of the first steps is if people want to get connected with our services with the Center for healthy aging we have a toll-free number here which is our if you have questions we have answers because we have a no long door policy we always strive to find the best way to help the folks in the community in any way possible and I'm gonna just jump in here and say that we're gonna have that on the screen at the end of the program but look for these because these are at libraries senior centers there are varieties of libraries we've even had people like real estate agents have them because they might identify someone that they work with in the community so you'd be surprised in any location you might see a Harford Healthcare Center for healthy aging but perfect that's the first step so if they call that one a seven seven toll-free number it will get fielded by your main program coordinator and they will take that message they will identify who's calling what it is they're looking for oftentimes they may not know specifically what services they really are looking for so it might start with getting turned over to one of our resource coordinators depending on what area or town they're calling from because they're all assigned different areas of the state of Connecticut and once we can have that assigned to the resource coordinator coordinator they will follow up with the family or a patient themselves directly have a much more in-depth phone conversation and discussing the possible home assessment or something like that if they're finding that there's a lot of medical concerns or their concern about medication management right from the get-go they may offer for a transitional care nurse to go out and do a visit at which point the resource coordinator will help facilitate a conversation with their primary care doctor and the primary care doctor will help with getting two orders signed and sent into our program for the transitional care team to go outs and once the transitional care nurses get that order we're actually the ones making those phone calls in real time to that patient family member or caregiver introducing our program interval within the center and you know determining what in time works for them so we can have that good two to three hour window to do the visit and with that's when we will go out and do that visit with them and oftentimes in our conversations we may find out that they have a lot of resource questions where we'll partner with one of our resource coordinators and even do a joint visit together or have one of our dementia specialists come in with us to do the visit if there's some cognitive or memory concerns to help provide you know a tag-team approach to address more concerns at one time as well I'm so glad that amina amina and you came in today to talk about this because we want to encourage people certainly to reach out and you're in the field all the time nicholas so what is something that you see time and time again a couple of the biggest issues we run into more often than not our medication errors and discrepancies is one of our largest concerns a well over 90% of our visits that we do we identify some form of medication error or discrepancy which really allows us to take that time in energy to really educate on what their medications are for because research has shown time and time again medication errors is one of the top causes of admissions to the hospital or visits to the emergency room so it really gives us the opportunity again to be proactive and identify those concerns that early enough to prevent those from becoming problems and especially these days the cognitive issues memory problems are really starting to show up a lot more as our population is aging which is a large percentage of the folks we see in the home so a lot of times we're really doing a lot of memory screening in cognitive screenings in the home using a lot of evidence-based practice to really identify and sometimes be the first ones to identify that maybe there's something more going on going on so Bravo Bravo to Hartford healthcare for taking this step forward and saying let's meet people where they're at which is where people want to be which is their home except and don't deal with the what-ifs and wonder about the what-ifs find out the answers and make that phone call and we're so happy that you came in today and we encourage you to reach out to Hartford healthcare the Center for healthy aging and have your process of aging at home be one that's filled with information kindness compassion and a friendly smile from all of us at Nutmeg TV we'll see you next time you

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