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.

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.

The Adult Health Care Home Patient

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.

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

Who is the Health Care Home Team?

Patient and Primary

Care Healthcare

Team

Patient-Centered Care

Subspecialty

Consult Tran

sition

from

th

e Hos

pita

l

Transition to

a Nursing

Home

Communicati

on with Public

Health Nurse

Com

mu

nic

atio

n

with

Sch

ool

Distric

t

Patient Stories

Patient-centered Care

81 year-old male

51 year-old male

50 year-old female

Services Provided 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

Lead Local Community Resources for Seniors with Disabilities

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

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

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

Final Thoughts