By Liz Lawson-Young, Marketing Specialist
CareWell Services Southwest’s Care Transitions Coordination and Support (CTCS) program seeks to reduce the risk of readmission for adults over age 60 after returning home.
CTCS Community Health Workers identify barriers for a successful transition back into a home setting and then create a person-centered plan to remove those barriers, meet medical needs, and engage other community-based resources for ongoing support.
“We assist in health navigation, health coaching, providing short term services, enabling our client to be successful after discharge,” said Mindy Sparks, Community Health Worker and Resource Advocate at CareWell Services. “Clients are able to stay out of the hospital, reduce the cost for themselves, and manage their conditions successfully.”
The program provides short-term supportive services to seniors at home through funding from the State of Michigan. Adults aged 60 and over residing in Barry and Calhoun county may be eligible for CTCS if they are currently admitted to a hospital and are not transferring to a skilled or supportive facility.
“This is an important program for seniors in our community which helps support recovery, improves health and quality of life, and reduces the risk of another hospital stay,” said Paulette Porter, Chief Operating Officer of CareWell Services.
Support through the program begins before a patient is discharged. A Community Health Worker will meet with the individual in the hospital to determine discharge plans, which includes completing an assessment, identifying barriers, needs, and supports, and creating goals. Once the individual is discharged, the Community Health Worker will coordinate with services, including the primary care physician, to ensure all identified needs are met.
“I love assisting my clients to ensure they have the tools and services they need to be successful and remain healthy in their own home,” said Sparks. “Watching them gain confidence and play an active role in their health and wellbeing is one of my favorite parts about my job.”
Referrals for CTCS should be submitted by discharge planners or other medical professionals to CareWell Services. Once a referral is received, a Community Health Worker will confirm eligibility and reach out to arrange services.
CareWell Services Southwest is the Area Agency on Aging for Barry and Calhoun Counties. The mission of CareWell Services is to promote health, independence, and choice for seniors, persons with disabilities, and caregivers. For more information about CareWell Services’ programs, call (269) 966-2450 or visit www.carewellservices.org.
