Through two generous grants from The Harry and Jeanette Weinberg Foundation, Lutheran Services in America partners with The University of North Carolina at Chapel Hill (UNC) to scale Connect-Home, a proven model of care for older adults in rehabilitation to successfully transition home. Lutheran Services in America and University of North Carolina’s Dr. Mark Toles and his team have implemented Connect-Home at seven member organizations across the country. Connect-Home is an evidence-based transitional care model created by Dr. Toles that empowers older adults and their caregivers to manage older adults’ serious illnesses at home, improve function and prevent avoidable re-hospitalizations. In parallel to the work under this Collaborative, NIH has invested $1.9M in a R01 clinical trial of Connect-Home by Dr. Toles at UNC which will run through April 2022.
The Connect-Home model retrains existing staff at post-acute care facilities to begin the conversation and prepare an older adult and their caregiver for a safe and successful return home at the start of the older adult’s care stay. The aims are to honor patient preference in discharge planning and to educate and empower older adults and their family caregivers to successfully manage follow-up care needed at home. By design, Connect-Home targets six key care needs to optimize patient and caregiver needs at home including: 1) home safety and level of assistance; 2) advance care planning; 3) symptom management; 4) medication reconciliation: 5) function and activity; and 6) coordination of care.
- Lutheran Services in America Implementing Partners:
- National Lutheran Communities & Services (Rockville, MD)
- Samaritas (Grand Rapids, MI)
- Lutheran Social Ministries of New Jersey (Florham Park, NJ)
- Lutheran Services Carolina (Wilmington, NC)
- Lutheran SeniorLife (Mars, PA)
- Niagara Lutheran Health System (Lancaster, NY)
- Luther Manor (Wauwatosa, WI)
- About Connect-Home
- Publication in Geriatric Nursing Journal: "Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative" April 2021
- White paper: "Scaling up Transitional Care for Post-acute Care Patients and their Families"
- Research article: "Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers"
- Blog: "Connect-Home Phase 2 Launches"
For more information about Connect-Home, contact Ashley Washington at firstname.lastname@example.org.