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ECH Health Care Home

ECH Health Care Home. Why is Health Care Home important to Mayo?. The needs of the patient come first. The way we define and address our patient’s needs is changing. We use a team approach, with all team members working to the full extent of their licensure.

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ECH Health Care Home

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  1. ECH Health Care Home

  2. Why is Health Care Home important to Mayo? • The needs of the patient come first. The way we define and address our patient’s needs is changing. • We use a team approach, with all team members working to the full extent of their licensure. • We assess and address our patient’s needs beyond their chief complaint. • We address the needs of our patient population whether they are seeing us in the office or not. • We work more closely to coordinate care with the ED, hospital, care facilities and community partners. Our goal is to provide the right care, at the right time, in the right location, with the right provider.

  3. Adult (19-121) Chronic issues expected to last a lifetime. Medical equipment needed for daily living. Receiving outside resources related to medical issues. Patient/family unable to self-coordinate. Two or more co-morbid conditions. The Adult Health Care Home Patient

  4. Health Care Home Team • Patient • Patient appointment Coordinators (PAC) • Clinical Assistants (CA) • Medical Secretary • Nurses: Triage, Care Teams • Transition Program • Social Workers & Discharge Planners • Provider • RN Care Manager/Care Coordinator • Language Department

  5. Who is the Health Care Home Team? Communication with School District Transition from the Hospital Subspecialty Consult Patient and Primary Care Healthcare Team Patient-Centered Care Communication with Public Health Nurse Transition to a Nursing Home

  6. Patient-centered Care 81 year-old male 51 year-old male 50 year-old female Patient Stories

  7. Coordinating Specialty appointments Home advice for the home health agency Acute calls from the family Medication renewals Follow up calls after hospitalization Care Conference Coordination Home Health Agency coordination Arranged medical equipment Language, literacy, & cultural adaptations Services Provided

  8. Olmsted Co. Public Health Services: Long Term Care Consultation Personal Care Assessments (PCA) Case Management Community Alternatives for Disabled Individuals (CADI) Elderly Waiver 507-328-6400 Workforce Center: Counseling (Vocational Rehab. Specialist) Training Finding & Keeping a Job Assistive Technology Follow-up Services 507-285-7315 Lead Local Community Resources for Seniors with Disabilities

  9. Community Resources • Southeastern MN Center for Independent Living (Rochester SEMCIL): • Senior Companion Program • Disability Linkage Line (888-460-1815) • Transition Service • Assistive Technology • Nursing Relocation • Independent Living Skills • Peer Mentor Services • Ramp Project & Accessibility Services • 507-285-1815

  10. Community Resources • Extended Employment Long Term Support • Ability Building Center (ABC) • 507-281-6262 • Additional resources: • Senior Linkage Line: 800-333-2433 • United Way 211 (800-543-7709) • Intercultural Mutual Assistance Association (IMAA):507-289-5960 • Elder Network: 507-285-5272 • Rochester Senior Center: 507-287-1404

  11. Final Thoughts

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