Lancaster Physician Summer 2019 - 32

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Patient Advocacy

"People once thought of
post-acute and nursing home
care as a place where patients
convalesce," said internist and
geriatrician Dr. Nicole Osevala,
medical director for Post-Acute
Transitional Care at Penn State
Health, seen here checking in
with a patient at the Penn State
Health Rehabilitation Hospital.
"Our program changes that
by successfully transitioning
patients back home using a more
advanced model of care."

Penn State Health Post-Acute
Transitional Care Program

BRIDGING
HOSPITAL
TO HOME

W

hen patients return home after skilled nursing care or rehabilitation, they sometimes face new concerns. Their symptoms
may worsen. They may take the wrong medication or lack
transportation to their doctor's appointments. In these situations,
their only option may be returning to an emergency department.
The Penn State Health Post-Acute Transitional Care Program helps to solve
some of these issues. By providing patients discharged from Penn State Health
Milton S. Hershey Medical Center with a dedicated, interdisciplinary team-nurse
practitioner, registered nurse (RN) care manager, social worker, and pharmacist-
for up to 30 days post-discharge. The team has the ability to make home visits,
ensuring all patient needs are met.
"People once thought of post-acute and nursing home care as a place where
patients convalesce," said internist and geriatrician Dr. Nicole Osevala, medical
director for Post-Acute Transitional Care at Penn State Health. "Our program
changes that by successfully transitioning patients back home using a more
advanced model of care."
The program addresses a need faced by many central Pennsylvania residents.
"Patients who transition back home want to be compliant, but sometimes they

BEYOND THE HOSPITAL
This is the third article in a multi-issue series featuring how Lancaster County health systems help patients continue
on their path to healing after a hospital discharge.
FEATURED IN THIS ISSUE: Penn State Health
LANCASTER

32

PHYSICIAN



Lancaster Physician Summer 2019

Table of Contents for the Digital Edition of Lancaster Physician Summer 2019

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