Chronic medical conditions are pervasive in the U.S.  They account for 95% of all medical costs for older adults, age 65 + and nearly 80% of older adults have at least one chronic medical condition. In the Medicare beneficiary population, 68% have two or more chronic medical conditions. At the top of the list, in terms of hospital readmission is chronic heart failure (CHF).

CHF older adult patients typically benefit from help once they return home from their hospital stay. Seniors’ Resource Center has embarked on an innovative pilot program and in partership with Lutheran Medical Center (LMC) in Wheat Ridge.

A Perfect Homecoming

A Perfect Homecoming has ambitious goals for patients and we believe this will accomplish three important things for patients:

  • Improve overall quality of life
  • Reduce the risk of hospital re-admissions
  • Provide cost savings in our community.

When a CHF patient at LMC is ready for discharge, SRC staff members are ready to serve them. We can transport them from the hospital to the patients’ homes, take them to pharmacies and as the days and weeks go on, drive them to their medical appointments. SRC delivers three days’ worth of frozen meals to the individual, a welcomed benefit of participating in A Perfect Homecoming. SRC care managers meet with each patient, providing an assessment and a “game plan” to meet individual needs and promote enhanced well-being. We offer in home care as the patient recovers. This includes: light housekeeping, laundry, changing bed linens and other vital services. SRC developed two levels of care: the Gold Plan and the Silver Plan, which are customized for the individual patients and can be for thirty days or go up to ninety days of post-discharge care. Staff can feed pets and water plants, retrieve the mail and offer a sense of calm as the individual begins to heal. Hope for a brighter future is something intangible, yet part of the service, too, as SRC program staff members bring compassionate care to each patient.

Promise for the future

SRC knows that this pilot program holds great promise for scalability and we look to the future when we can offer this post-discharge program to patients in additional local hospitals.  We are pleased to be in partnership with LMC to grow A Perfect Homecoming.

A Perfect Homecoming was created from Seniors’ Resource Center’s participation in the Colorado Linkage Lab. CLL was funded through a generous grant from the Colorado Health Foundation.  Eight nonprofit organizations in the state were initially approved for CLL funding and tasked with designing and beginning implementation of a project. SRC staff members Terri Wager, Tia Sauceda, Steve Villano and CEO John Zabawa worked to create A Perfect Homecoming.  The implementation phase began when additional funding was secured from the Colorado Health Foundation along with support from Community First Foundation. LMC has also contributed support and the “green light” has SRC going forward. Throughout 2017, the pilot program will serve patients, gather and track data and produce results that can be replicated in additional hospitals throughout the greater Denver metro area.

Listen to more about the program

Recently Mary Ellen Carlow, SRC’s Grant Manager, was interviewed on No Copay Radio about the program. Her interview starts around minute 20.


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