Lancaster Physician Summer 2019 - 33

SUMMER 2019

don't have the support system in place to
manage their medications, attend doctors'
appointments, or fully understand their discharge instructions," said Patricia Anderson,
director of Post-Acute Transitional Care for
Penn State Health.

These internal medicine and geriatric medicine
providers embedded within post-acute care
facilities in Lancaster and Dauphin counties
see patients daily and coordinate care with
the facility's own nursing staff, pharmacists,
and therapists.

"That's why home visits are an effective
intervention, so patients can receive the right
level of care in a setting that is comfortable
for them."

The providers use established protocols to
treat patients in the post-acute care facility
without having to return to the hospital. "We
follow pathways to manage acute heart failure
exacerbations, pneumonia, and sepsis," Osevala
said. The program's providers also optimize
discharge and post-acute care.

The program initiates when the care team
prepares a patient for discharge from Milton
S. Hershey Medical Center. A social worker
or RN care coordinator meets with the patient
to discuss next steps and helps with those
arrangements. For many patients, that includes
a skilled nursing or rehabilitation facility. "We
base those choices on patient preference and
insurance requirements," Osevala said.
Within 72 hours of discharge, a Penn State
Health provider meets with the patient to support the transition to a post-acute care facility.

As patients prepare to return home, they're
assigned an RN care manager, social worker,
and pharmacist who reconcile medications and
connect patients with community resources.
The RN care manager then checks in with
the patient routinely to ensure he or she is
transitioning safely.
For all patients-including the many from
Lancaster who choose Hershey Medical Center

Michael Gray, left, a physical therapist with Penn
State Health Post-Acute Transitional Care, works
with Ted Botzum of Palmyra in the therapy room of
the Penn State Health Rehabilitation Hospital.

for care-the Post-Acute Transitional Care
team communicates with referring physicians
and specialists.
Each time the team treats a patient's condition without needing a hospital readmission,
it's a success. "Patients and their families have
often referred to our program as a warm hug,"
Anderson said.

Expanded Memory Care Coming in 2019
Your parents have shared a lifetime
together. But, what do you do when
their needs are so different?

2018 - M

Pleasant View's expanded memory
support services in Personal Care
now gives couples the option to
remain together, even if their
needs for daily care and memory
support vary.

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Anniv
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544 North Penryn Road, Manheim PA
www.PleasantViewrc.org | 717-664-6237

LANCASTER

PHYSICIAN

http://www.PleasantViewrc.org

Lancaster Physician Summer 2019

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