The Care Transitions Program will be an important element of the Kane Clinic. The goal of the program is to support Martin County elders as they transition from a variety of health care settings from/to home. Support will be provided through the programs and services of the Council on Aging of Martin County, including full access to the health services of the Clinic. An additional goal of the Care Transitions Program is to help reduce hospital readmissions.
It is projected that the Care Transitions Program will assist at least 80 frail elders in its first year with health and social service needs, as they are admitted, treated by and leave a hospital in-patient stay or emergency room care or a rehabilitation nursing facility stay. The Care Transitions Program will enroll an additional 80 new patients each year following the initial year.
The Kane Clinic will be one cornerstone of the Care Transitions Program, with the Kane Clinic Geriatrician/ Medical Director and the advanced registered nurse practitioner (ARNP) available for in-clinic appointments and the ARNP also available for in-home visits.
Supportive services for the patient and the caregiver, if present, will be arranged and coordinated by the care management staff of the Council on Aging of Martin County, an interdisciplinary team comprised of an RN and social workers. In addition, an on-call RN will be available 24/7. The model features three community assets that most care transitions models do not include:
- the senior center;
- the Clinic within the senior center; and
- an adult day program, which is housed at the Kane Center adjacent to the Clinic.
