Aging Care Connections implements both the evidenced-based Bridge model of transitional care onsite at AMITA Health Adventist Medical Center La Grange and the Ambulatory Integration of the Medical and Social (AIMS) model onsite at AMITA Health La Grange Family Medicine Center and AMITA Health Medical Group Family Medicine Westchester. Both models are relationship-based, person-centered approaches to assist older adults and their caregivers with medical care plan follow through, as well as address any unmet non-medical needs. The Bridge model focuses on assisting clients with the discharge home from the hospital, whereas AIMS focuses on assisting clients of the two partner physician practices.
Both programs are driven by master’s-prepared social workers who meaningfully engage each client by getting to know their strengths and preferences. Social workers apply a thorough assessment to address the many factors that may impact a client and their caregiver’s health and well-being. The client directs their own care by identifying personal wellness goals, building a collaborative care plan with the social worker for how to reach those goals and problem-solving barriers to goal attainment. The social worker plays the quarterback in the client’s care by collaborating with relevant healthcare and community-based providers to resolve gaps in care to ensure a seamless continuum of health and community care across settings.
Aging Care Connections also implements the Choices for Care program out of the hospitals and skilled nursing facilities within our service area for anyone 18 and older seeking short or long term nursing facility placement. Care Coordinators conduct a short assessment to determine client and caregiver needs, educate clients on home and community-based services available to them, and implement expedited non-medical services for clients returning home from a hospital or skilled nursing facility.
The Community Response Network (CRN) is comprised of local businesses, non-profits, and volunteer agencies that are dedicated to working together to address the needs of older adults transitioning home from the hospital in a timely manner. The goal of the CRN is to expedite community-based services for older adults leaving an acute and post-acute care setting and their families to ensure a safe return home and find solutions for existing gaps in services. Click here to learn more about the CRN.
Both programs are driven by master’s-prepared social workers who meaningfully engage each client by getting to know their strengths and preferences. Social workers apply a thorough assessment to address the many factors that may impact a client and their caregiver’s health and well-being. The client directs their own care by identifying personal wellness goals, building a collaborative care plan with the social worker for how to reach those goals and problem-solving barriers to goal attainment. The social worker plays the quarterback in the client’s care by collaborating with relevant healthcare and community-based providers to resolve gaps in care to ensure a seamless continuum of health and community care across settings.
Aging Care Connections also implements the Choices for Care program out of the hospitals and skilled nursing facilities within our service area for anyone 18 and older seeking short or long term nursing facility placement. Care Coordinators conduct a short assessment to determine client and caregiver needs, educate clients on home and community-based services available to them, and implement expedited non-medical services for clients returning home from a hospital or skilled nursing facility.
The Community Response Network (CRN) is comprised of local businesses, non-profits, and volunteer agencies that are dedicated to working together to address the needs of older adults transitioning home from the hospital in a timely manner. The goal of the CRN is to expedite community-based services for older adults leaving an acute and post-acute care setting and their families to ensure a safe return home and find solutions for existing gaps in services. Click here to learn more about the CRN.