Improving the Health of Older Adults with Chronic Conditions

by Fran Anderson, Director of The Center For Aging, Senior Services of Southeastern Virginia

Ms. Rosa has just returned home after her second hospital stay within a month. She is 66 years old and has several chronic conditions with 12 prescribed medications. Ms. Rosa sees two doctors and uses two different pharmacies. Her medications were adjusted during her inpatient stay resulting in several new prescriptions. She feels overwhelmed by all the instructions she received in the hospital. She is confused about the medication changes. Ms. Rosa is the caregiver for her husband who has dementia. She also often babysits her grandchildren. She knows she needs to take better care of herself but she is worried that she can’t do that when so many others are relying on her. Fortunately support for Ms. Rosa is available.

Nearly one in five Medicare patients will be readmitted within 30 days of a hospital discharge. (Rau) This research also shows that 72% of adverse events following a hospital stay are related to medications and that medication errors are the fifth leading cause of death among older adults. (HomeMeds.org) Many hospitalizations and medication related problems are preventable.

Senior Services of Southeastern Virginia (SSSEVA) a private nonprofit Area Agency on Aging has been implementing a pilot program since 2013, the Hampton Roads Care Transitions Project (HRCTP). The goals of the pilot are: 1) to reduce preventable hospital readmissions for adults 60 and older with chronic conditions and 2) to address medication management across transitions of care from hospital discharge to the patient’s home. Sentara Leigh Hospital, Norfolk General Hospital, and Hampton University School of Pharmacy are collaborating partners with SSSEVA on implementation. The pilot is funded in part by the John Hartford Foundation and the Cardinal Healthcare Foundation. Two evidence based programs, the Care Transition Intervention® (CTI®) and HomeMedsSM are being used in the pilot. CTI and HomeMeds are models that have proven to be effective in assisting seniors to remain in their home, reducing hospitalizations, promoting health, and reducing healthcare costs...

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