Glen Transitional Pathway

Glen Transitional Pathway

The Glen Transitional Pathway is a person-centered, social work-led, interdisciplinary model of transitional care. Our Transitional care model emphasizes collaboration among hospitals, community-based providers and the Aging Network in order to ensure a seamless continuum of health and community care across settings.


At Glen Oaks, we follow our guests for 30 days after discharge from our rehabilitation or skilled services to assure they are connected to necessary resources for successful return home and to assure our guests do not experience any further unnecessary hospitalizations. Listed below are just a few needs that may occur once our guest has returned home that we will monitor and work with for 30 days following discharge home.


Client, Caregiver and Resource Needs - Examples:

  • Discharge plan confusion
  • Low patient activation
  • Poor health literacy
  • Insurance / financial issues
  • No primary care provider or PCP
  • Unable to afford medications
  • Mental/emotional health concerns
  • Cognitive impairment
  • Pain
  • ADL limitations
  • Caregiver stress
  • Inadequate social support
  • Substance / medication abuse
  • Abuse / neglect or self - neglect
  • Community resource / support need
  • Safety / environment
  • Legal / guardianship
  • Transportation


Intervention

  1. Provide follow-up on outstanding referrals, issues, equipment, and appointments identified.
  2. Share missing / new pertinent information with providers.
  3. Actively collaborate with providers to resolve issues. Should be referred to Home Health, Palliative, Meals on Wheels, etc.
  4. Facilitate communication among providers.
  5. Facilitate provider engagement with client.
  6. Encourage patient activation
  7. Provide educational support to client/ caregiver
  8. Provide emotional and therapeutic support to client / caregiver
  9. Identify additional needs and resources and make appropriate connections
  10. Identify and improve all systemic problems.