HELPLINE: 1-800-642-5119

 

care transitions your path home 2

When it’s time to come home from the hospital or rehabilitation, Age Well’s Care Transition team can guide your road to recovery. Services are provided to those 60 and over (regardless of income) and aim to reduce costly and avoidable hospital readmission.

In preparation for discharge, we will administer a services assessment, communicate with providers, assist with medication reconciliation (HomeMeds), and develop an action plan to create a continuum of care.

Transitioning after a hospital visit can be hard work—we come to this process with expertise, patience, and the commitment to make your return home a successful one. Are you in need of support? Please call our Helpline: 1-800-642-5119.

 

Choices for Care

Are you or a loved one looking for a way to age at home, but need help coordinating and paying for care?

Age Well is equipped to make an independent lifestyle a reality. As a Choices for Care provider, Age Well offers you a continuum of care. We will coordinate a customized, in-home visit to connect you with the necessary resources, assist with everyday activities, and make informed decisions.

What is Choices for Care? Am I eligible?

Choices for Care is a Medicaid-funded, long-term care program that pays for care and support for older Vermonters and people with physical disabilities. This program helps people with everyday activities at home, in an enhanced residential care setting, or in a nursing facility.

To be eligible, you must:

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  • Be a Vermont resident,
  • Be at least 65 years old OR at least 18 years old with a physical disability,
  • Meet the financial criteria, and
  • Meet the clinical criteria for nursing home level of care.

 

What is Age Well’s role as your Choices for Care provider?

Age Well connects you with one of our Care & Service Coordinators, who will assist you with gaining access to medical, social, financial and other supports. To establish a continuum of care, your Care & Service Coordinator will meet with you wherever you are and complete an initial assessment. This meeting will determine the number of hours of care necessary and services available to you through Choices for Care. Once a plan is in place, we will coordinate services and monitor any changes in your circumstances to help you remain independent for as long as possible.

Why choose Age Well as your Choices for Care provider?

When you choose Age Well, you have an entire network of services at your disposal, including HomeMeds, Meals on Wheels, the Helpline and over 40 years of experience.

To learn more about Choices for Care, call the Helpline at Age Well: 1-800-642-5119.

HomeMeds

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As part of Care Transitions, Age Well offers HomeMeds, an evidence-based, in-home medication management tool. This program identifies risks and ensures that current medications are being appropriately taken and updated.  

pdf Click here to download more information about the HomeMeds program. (241 KB)

  1. Age Well's transition team conducts a risk screening to identify potential errors and medication-related problems.
  2. Any potential medication risks or identified problems alert the Care & Service Coordinator to notify Age Well's designated pharmacist.
  3. The pharmacist reviews and develops an action plan of recommendations to address the identified alerts.
  4. The pharmacist advises the client or caregiver and the Care & Service Coordinator of the medication concerns so that they can be discussed with the physician.
  5. Physicians are able to review all compiled data and update the client’s treatment regime if an issue is revealed.

Medication related problems and errors are...

  • Serious: They cause approximately 7000 deaths per year in the US.
  • Costly: Annual cost of drug-related illness and death exceeds $170 billion.
  • Common: Up to 48% of community-dwelling elders have medication-related problems.
  • Preventable: At least 25% of all medication-related accidents and health problems are preventable. If you have patients or loved ones who may benefit from this service, please contact the Helpline at 1-800-642-5119 to learn more.

Note: all alerts, physician responses and medication changes are recorded to keep a detailed medication record.

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© 2017 Age Well, All Rights Reserved
76 Pearl Street, Ste. 201 Essex Junction, VT 05452
Age Well is a 501(c)3 nonprofit. Donations are tax deductible.
P 802-865-0360 F 802-865-0363, HELPLINE: 1-800-642-5119