Coaching and support so you can remain at home
Lutheran Social Service of Minnesota offers coaching and support to assist patients for the first 30 days during a transition of care from a hospital or care facility back home. 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.
Health Benefits for Patients:
- Stay healthy and independent.
- Remain at home and out of the hospital or emergency room.
- Receive social connection and ongoing support.
- Feel safer at home.
- Learn new skills and get nutrition tips.
- Plan for medical appointments.
- Support to tackle challenges and make lifestyle changes.
- Gain a better understanding of medications.
Benefits for Care Coordinators:
- The CHW collaborates with you to support the patient.
- The CHW and patient work together to reach healthy goals.
- The CHW is your consistent eyes and ears in the home during the patient’s transition.
- The CHW saves you time by coordinating additional supplemental benefits and finding more resources for the patient.
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.
- Fall prevention support for patients.
- Encourages the use of primary care and other non-emergency services.
- Reduces hospital readmissions and lowers overall health care costs.
One of our LSS Healthy Transitions partners tracked claims data for individuals served in an 18-month period. They found that none of the 113 members had a subsequent inpatient admission within 90 days of hospital discharge.
"I am grateful for the LSS Healthy Transitions. The CHW 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 CHW in a way that made me feel understood. I felt like she has gone through things, too. I could have gone on to have 11 more visits with the community health worker, as she understood me so well."
– Patient who received the service
Partner With Us – Get Started Today
To learn more about how LSS Healthy Transitions 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.