Transitional Care Program for Seniors
Mills-Peninsula offers inpatient hospital care to more than 7,000 seniors (65 and older), accounting for nearly half of all admissions annually. Within this group, 15 percent are re-admitted within 30 days, 25 percent within 90 days, and 31 percent within 180 days.
These statistics can be explained by the fact that many older adults experience breakdowns in care during the transition from hospital to home. This results in high rates of poor outcomes and rehospitalization. Elders with multiple medical problems, functional deficits, cognitive impairment, emotional problems, and poor general health are at particular risk during this transition. So are racial/ethnic minorities, non-English speakers, and immigrants.
- Lack of care coordination among different care settings
- Social problems such as living alone, providing care to another senior or lack of financial stability
- Not being connected to available community resources
- No follow-up visit with a physician
Specifically, the program will establish:
- A short-term intensive stabilization care model
- A long-term "Buddy Program" that monitors the ongoing care plan to sustain the patient in the community after discharge
Our ultimate goal is to design a patient-centered transitional care program for senior patients with complex medical and social needs that will integrate and coordinate services and care across the continuum, from hospital to home, and provide ongoing services to foster independence.
We have charted a plan to make this vision a reality and now we invite you to partner with us in this endeavor. For more information about how you can support this project, please contact John Loder, president of Mills-Peninsula Hospital Foundation, at email@example.com or 650-696-5958.
Make a donation to the Transitional Care Program for Seniors