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500th Patient Enrolled in Transitions of Care Program

500th Patient Enrolled in Transitions of Care Program

The Transitions of Care program celebrated the enrollment of its 500th patient in August. This program is designed to improve the experience of patients transferring from the hospital to a skilled nursing facility by increasing their satisfaction and reducing their anxiety.

A three-year grant, funded by the Health Resources & Services Administration (HRSA), helped the West Plains medical community create a Transitions of Care consortium among Ozarks Medical Center (OMC), Brooke Haven Health Care, National Health Care, and West Vue Nursing and Rehabilitation. The grant runs from May 2015 to April 2018.

“In the short time the program has existed, we have seen spouses or siblings of former patients become enrolled,” said Addy Van Os Keuls, MSW-Program Director at OMC. “It is so rewarding to come across someone from the community who is already aware of our services and looks forward to having them for themselves because they know how beneficial they are.”

Patients enrolled in this program are assigned a Transitions Coach while still in the hospital. This coach acts as a liaison between the hospital and nursing facility to keep all lines of communication open. After patients arrive in the nursing facility, coaches visit patients weekly to make sure patient needs are met, doctor’s orders are carried out, and medications are accurate. The coach may also set up transportation to appointments or meals on wheels, when needed.

Since the Transition of Care’s inception, 89% of patients or family members surveyed felt the program relieved anxiety about the nursing facility transition, 86% reported increased satisfaction with their nursing facility, and 90% felt increased satisfaction with their OMC experience.

Only patients who meet specific criteria may enroll. For questions about eligibility, call the program director at 417-257-5826.

Pictured from left to right: Lisa Schiffleger, Data Specialist; Addy Van Os Keuls, MSW, Program Director; and Ranae Rutledge, Transitions Coach.

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