Care Coordination
Care Coordination is a free service that is designed to help clients manage their health after returning home from the hospital. Clients benefit from personalized support and range of services offered directly by Homage. Results include increased confidence in navigating the healthcare system, greater awareness of and access to community resources. We have experience working with older adults and people with disabilities and are happy to talk with you further about how to support you as you transition home.
Homage Care Coordinators receive referrals from Providence Everett and Swedish Edmonds, as well as local medical providers. Care Coordinators meet with patients to schedule their first visit, either in the hospital or when they return home. This visit will include an initial evaluation and preliminary care plan development tailored to the client’s specific needs. Care Coordinators assist clients in reviewing and better understand their health status, to identify ‘red flags’ that may lead to risk of readmission, ensure follow-up appointments and transportation are scheduled, review medication adherence and coordinate resources to encourage recovery. Resources provided directly by Homage include in-home care coordination, transportation, meal delivery, and fall prevention education.
Eligibility:
- Has one or more chronic conditions including: CHF, COPD, Diabetes, Asthma, Chronic
- Kidney Disease, Cancer, Parkinson’s, MS, Autoimmune Disorders
- Hospital admission or high risk for admission referred by physician.
- Hospitalization within the past twelve months.
Services Offered:
- In-home Care Coordination
- Transportation
- Home Delivered Meals
- Fall Prevention Education
Patient Outcomes:
- Reduced risk of readmission
- Reduced risk of ED visits
- Improved awareness of available medical and non-medical resources
- Increased Healthcare IQ / health literacy
- Increased well days
- Decreased length of stay