SC Hospitals Push Coordinated Care

John Commins, for HealthLeaders Media , April 10, 2013

Foster says it's critical to leverage the existing resources that will vary from community to community.

"Maybe the same volunteers doing Meals On Wheels we could provide some basic training on how to be a home health coach and at least provide basic assessments of patient needs," he says. "Then you may have a second level where you have some folks with clinical training. We are doing a pilot in one rural community here around community para-medicine. We take paramedics when they're not on calls to clinical evaluations or withdraw blood for evaluations. They can go to the homes of the highest risk patients."

"We have some communities where retirees are being trained to be community health workers. We have some communities working with a university or a college and they are getting students to do this. It's a matter of looking at the resources in the community, what already exists, and how to connect them in a more efficient way. Until now they've been kind of in their own silos."

These home health visits will allow providers to evaluate and address living space issues for patients that would go unnoticed inside the hospital walls."

"There will be patients with high readmissions rates that just have a very poor environment as far as they don't have a good social infrastructure with family members or access to transportation. Those are the ones where having the Meals On Wheels and having someone come into their home to check on them is important."

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