Southwestern Vermont Hospital:
Older adults with complex health needs can experience a breakdown in continuous care when moving from a hospital setting to their own homes. Adapting the Transitional Care Model in a rural context, this project aims to design and share plans of care and identify gaps in the delivery of integrated health care in the Bennington Service Area. The project has created an interdisciplinary Community Care Team to better meet the needs of behavioral health patients and those with drug and alcohol addictions who frequent the Emergency Department at Southwestern Vermont Health Care (SVHC). One hoped-for outcome is to decrease the number of hospital admissions and Emergency room visits of high-risk chronic care patients in the region. Data from 120 days before and after using the Transitional Care Program demonstrate a 35% decrease in Emergency Department visits and a 69% decrease in Inpatient and Observation Hospital stays for 267 patients enrolled in the program.