• Hospital to Community Support

    Background

    Rehabilitation is a process that enables a person to regain or relearn skills lost due to neurologic or structural injury, health conditions and aging. An optimal rehabilitation system includes a continuum of treatment from hospitalization to community-based programs. Guaranteeing a continuum will facilitate earlier release from rehabilitative hospital units and the patient’s return to his or her natural environment. This will reduce the need to develop institutions for long-term care and will lead to savings in healthcare costs.

    Although Israel boasts relatively low rates of hospitalization and institutionalization, a lack of knowledge and appropriate care often leads to repeated hospital stays for the same ailment. Hospital stays often have negative effects on both the physical and emotional health of patients. Recovery after a hospital stay can be a difficult process, especially for older adults who may not understand the necessary but complex rehabilitation steps.

    Need

    A continuum of care from the hospital to the community in order to ensure the functional, mental, and nutritional status of a patient is maintained while in the hospital and at home after hospitalization.

    Program

    Eshel operates three programs aimed at preventing re-hospitalization, each run through a different hospital. This program identifies older adults at risk and works to preserve their functional abilities in the hospital and throughout their transition home.

    Volunteers in the Rambam pilot program work with patients to maintain cognitive and physical function by engaging patients in regular conversation, assisting patients get out of bed and leading patients in light exercise activities during the day.

    The Tel Aviv pilot program assists older adults and their caregivers to integrate back into the community after a prolonged hospital visit. Volunteers provide valuable information and advice about rehabilitation options, benefits and services, and long-term plans for health and well-being.

    The pilot program in Afula focuses on patients in palliative care and helps connect patients to community services.

    Outcomes

    • Decrease in re-hospitalizations
    • Feels secure due to presence of support network
    • Aware of and utilizes available rights and services in accordance with needs
    • Optimal physical and cognitive functional ability

    Contract dates

     

    Partners

    Reut