Ensuring Successful Transitions from Hospital to Home
Lutheran Social Service of Minnesota (LSS) offers individualized companion support and helpful resources to assist older adults during the first 30 days after they leave the hospital. We are currently partnering with multiple hospitals and major health insurance partners.
How it Works
- After discharge from the hospital, a specially trained and certified LSS Community Health Worker (CHW) contacts the patient to let them know what to expect.
- Within 72 hours of discharge notification, the CHW calls the patient to schedule visits by phone or in person.
- During visits, the patient and CHW develop goals, review medications, conduct a home safety assessment and discuss community resources, nutrition and upcoming medical appointments.
- The CHW communicates consistently with the care coordinator throughout the service to ensure a safe and healthy transition.
One of our Community Companion health plan partners tracked claims data for members served in an 18-month period between 2018-2019. Zero out of 113 members had a subsequent inpatient admission within 60 days of service completion.
Health Benefits for Individuals
- Stay healthy and independent, out of hospital or ER
- Social connection and an ongoing resource for questions
- Feel safe at home and get nutrition tips
- Planning to get to medical appointments
- Support to tackle challenges and make lifestyle changes
- Better understand medications
Benefits for Health Care Partners
- Customized to meet your needs
- Fills the gap between hospital and home
- Supports patients who are high utilizers of services
- Option to add LSS Meals to Go frozen shipped meals
- Customized outcome reports
- Transitions patients to use primary care, instead of relying on the ER or ambulance services
- Reduces hospital readmissions, and better outcomes can lower costs and increase reimbursement rates
"I am grateful for the Community Companion Service. The Community Health Worker connected me to some great resources so that I can feel safe at home. I don’t want to go back to the hospital if I can help it!”
—76-year-old woman who received the service
"I connected with the Community Companion in a way that made me feel understood. I felt like she herself has gone through things too. I could have gone on to have 11 more visits with the Community Companion, as she understood me so well."
–Community Companion client
Get Started Today
To learn more about how Community Companion can work for your organization, contact Melissa Grimmer, Program Director. Call 651.310.9443 or toll-free at 888.200.0986 or email Melissa.Grimmer@lssmn.org.