To meet the many needs of those with advancing illness, LifeSpring In-Home Care Network is pleased to introduce our Turning Point Care Program. This pre-hospice program is a component of our full-service home based care organization, and serves those who may have a life-limiting illness, but are not yet ready to elect hospice care, or who do not yet meet Medicare’s stringent eligibility requirements for this care.

LifeSpring’s Turning Point Care Program assists our acute and post-acute care partners to follow patients who may soon need hospice to successfully transition to their home setting. We provide follow-up visits, calls, and services to patients identified by hospital case manager and care staff as being at high risk for:

• Future need for hospice care
• Rehospitalization
• Potential need for urgent care
• Falls with injury
• Adverse effects of potent and/or multiple medications
• Exacerbation of pain, shortness of breath, or other serious symptoms
  

Features of the program include:

1. A hospital nurse, case manager, or social worker identifies a patient appropriate for the program, and makes the referral to LifeSpring’s Turning Point Program.
2. A specially trained hospice social worker or nurse calls the patient to schedule a home assessment within 48 hours of hospital discharge. The purpose of this visit is to:
   • Identify resource and care needs
   • Assess patient’s / family’s ability to manage care in the home
   • Evaluate emerging needs which might prevent rehospitalization
   • Ensure the patient has scheduled and attends a follow-up visit with their PCP or other appropriate physician
   • Determine appropriate schedule for follow-up contact
   • Educate patient/family regarding available resource options, including:
     • Telehealth
     • Hospice informational visit
     • Personal care/ companion options for respite or other physical support needs
     • Local support groups
     • Other resources, such as Meals on Wheels and Medication Assistance
       
3. The home visit is followed by one to three follow up phone calls from our Turning Point call center staff, following a customized telephone visit script, over the next 14 days. The focus of the calls is to address physical, social, and resource needs of the patient and caregiver. Our telephone visit scripts are customized to disease states, including:
   • Congestive Heart Failure
   • Chronic Obstructive Pulmonary Disease
   • Cancer
   • Alzheimer’s Disease/ Dementia
   • Neurological Diseases
   • General 
     
4. We follow up on identified resource needs of the patient, and may, as appropriate, request physician orders for additional care or services, such as:
   1. Medical equipment
   2. Home health care services
   3. Hospice services
   4. Physician’s appointment
   5. Respite care
   6. Personal care services
   7. Other resources to enhance quality of life 
      
5. Our hospice social worker or nurse will provide a written and/or verbal report back to the referring facility case manager regarding the patient status and outcomes of the program.

 

LifeSpring’s Turning Point Program is a professionally managed program designed to assist those challenged by an advancing illness. Our program is available to residents of the following counties:

• Oklahoma
• Canadian
• Cleveland
• Garvin
• Grady
• Hughes
• Lincoln
• Logan
• McClain
• Pottawatomie
• Seminole

 

 

Please contact us for more information!

LifeSpring Hospice
Phone:  (405) 329-2290
Fax:      (405) 310-3371