ECH Health Care Home Why is Health Care

ECH Health Care Home

Why is Health Care Home important to Mayo? n n n The needs of the patient come first. The way we define and address our patient’s needs is changing. We use a team approach, with all team members working to the full extent of their licensure. We assess and address our patient’s needs beyond their chief complaint. We address the needs of our patient population whether they are seeing us in the office or not. We work more closely to coordinate care with the ED, hospital, care facilities and community partners. Our goal is to provide the right care, at the right time, in the right location, with the right provider.

The Adult Health Care Home Patient Adult (19 -121) n Chronic issues expected to last a lifetime. Medical equipment needed for daily living. Receiving outside resources related to medical issues. Patient/family unable to self-coordinate. n Two or more co-morbid conditions. n n n

Health Care Home Team n n n n n Patient appointment Coordinators (PAC) Clinical Assistants (CA) Medical Secretary Nurses: Triage, Care Teams Transition Program Social Workers & Discharge Planners Provider RN Care Manager/Care Coordinator Language Department

Communication with School District Su bs p ec i al ty C on su T th ran e H sit os ion pi fr ta om l Who is the Health Care Home Team? lt Patient and Primary Care Healthcare Team to a n o iti ome s n H a Tr rsing Nu Patient-Centered Care Com wit muni h c Nur Publ ation ic H se ealt h

Patient Stories Patient-centered Care n 81 year-old male n 50 year-old female

Services Provided n n n Coordinating Specialty appointments Home advice for the home health agency Acute calls from the family Medication renewals Follow up calls after hospitalization n n Care Conference Coordination Home Health Agency coordination Arranged medical equipment Language, literacy, & cultural adaptations

Lead Local Community Resources for Seniors with Disabilities n n n n Olmsted Co. Public Health Services: Long Term Care Consultation Personal Care Assessments (PCA) Case Management Community Alternatives for Disabled Individuals (CADI) Elderly Waiver 507 -328 -6400 n n n n Workforce Center: Counseling (Vocational Rehab. Specialist) Training Finding & Keeping a Job Assistive Technology Follow-up Services 507 -285 -7315

Community Resources n n n n n Southeastern MN Center for Independent Living (Rochester SEMCIL): Senior Companion Program Disability Linkage Line (888 -460 -1815) Transition Service Assistive Technology Nursing Relocation Independent Living Skills Peer Mentor Services Ramp Project & Accessibility Services 507 -285 -1815

Community Resources n Extended Employment Long Term Support n Ability Building Center (ABC) 507 -281 -6262 n Additional resources: n n n Senior Linkage Line: 800 -333 -2433 United Way 211 (800 -543 -7709) Intercultural Mutual Assistance Association (IMAA): 507 -2895960 Elder Network: 507 -285 -5272 Rochester Senior Center: 507 -287 -1404

Final Thoughts