News and Updates for August 2024

News & Updates

August 2024 | Volume 2, Issue 11

ESCCI Now "Embedded" in Hospital

In a typical year, as many as 4000 patients will be discharged from Cape Cod Hospital needing some sort of ongoing in home healthcare services to support recovery and prevent readmission to the hospital. But these transitions don’t always go smoothly. Patients might not accurately assess their physical condition or period of convalescence. Care teams might not fully understand the patient’s living situation. That’s where Terri Richerson, Elder Services’ new Hospital Liaison comes in. Richerson’s charge is to work with the hospital’s discharge staff, case managers, and social workers to ensure a smooth transition from hospital to home. “The case managers are happy to see me,” Richerson reports. “They know I can help get the services patients need.”

The Commonwealth of Massachusetts launched the Hospital to Home Partnership Program to build stronger relationships between acute care hospitals and community providers by contracting with Aging Services Access Points such as Elder Services of Cape Cod and the Islands. Although the program has been around since 2022, our agency was only awarded funding in the most recent and final round of the pilot. Richerson began her new role, working from within the hospital itself, just two weeks ago and already has assisted 35 patients.

As a registered nurse and Elder Services’ employee, Richerson can accurately communicate with patients the details of services and programs that can create a continuum of support and care. For those patients who are already clients with Elder Services, Richerson can communicate directly with their care manager about scheduling services and make internal referrals to specialized programs. For those who are not Elder Services’ clients, she can start the eligibility review based on the patient’s medical records, while the patient is still hospitalized.

The Executive Office of Health and Human Services is closely monitoring outcomes of this three-year program to determine whether or not it succeeds in closing the knowledge gaps and improving coordination across agencies. And to learn whether better understanding and communication will improve health outcomes for patients—because that’s the very real concern behind these efforts.

Responding to Substance Use and Abuse by Older Adults

By Stephanie Ficher, Managed Care Officer

On June 11, several staff members from the Home Care and Health Services, Senior Care Options, and Protective Services Departments, attended the Aging with Dignity Conference at College of the Holy Cross in Worcester. Organized by the Massachusetts Department of Public Health’s Bureau of Substance Addiction Services, the day was devoted to exploring the intersection of aging and substance abuse. Elder Services of Cape Cod and the Islands is committed to the ongoing professional development of its staff, and the focus of this conference aligned well with their experiences in the field.

The American Psychiatric Association defines Substance Use Disorder (SUD) as a complex condition in which there is uncontrolled use of a substance despite harmful consequences. SUD exists on a spectrum and may be mild, moderate or severe. It typically involves an overpowering desire to use the substance, increased tolerance to the substance and/or withdrawal symptoms when you stop taking the substance. At the “Aging with Dignity” conference, experts from across the country offered workshops on a range of topics including the intersection of grief or depression and substance abuse, the effects of past substance abuse on health in later life, and how to stabilize housing for substance abusing older adults.

“I have been in the geriatric field for ten years, and substance abuse in the older population was not something we really talked about or even spent much time learning about when I was in school, getting my psychology degree,” says Shelby DeCosta, Senior Care Options Program Manager. “It wasn’t until I began working here at Elder Services that I really experienced first-hand how substance abuse among the older adults is real and is happening every day. People don’t like to talk about it. It’s uncomfortable and the stigma it carries is heavy.”

According to the Center for Behavioral Health Statistics . . .