You’re invited to learn about the Navigator Program for Successful Aging©. This innovative program developed by Partners in Senior Care addresses how independent and assisted living facilities approach individual wellness and transitions of care. The goal is to improve resident health, prevent hospitalizations and re-hospitalizations, decrease disease exacerbations and successfully navigate transitions of care.
The Navigator Program identifies the top reasons for hospitalizations and leave of absences in a particular retirement community (such as CHF or COPD, falls, pneumonia or urinary tract infections.) General wellness programs are developed to address these top reasons and are globally implemented by the community.
During transitions of care, the personal navigator advocates and coordinates between all providers to maintain accountability, ensure medication reconciliation and understanding of the resident’s baseline status. The navigator assists discharge planners to look beyond the initial next step for the resident to the long-term goals of the resident and family. Education, advocacy, and communication are key for the resident and family, as well as providers, to facilitate an appropriate, comprehensive, successful discharge plan.
Upon discharge, the navigator guides and educates the resident through recommended lifestyle changes adding them to their Passport to Wellness. Medications are reconciled by a registered nurse and reviewed with the resident to confirm understanding. If home health care is required, the navigator collaborates with the home health agency to ensure discharge orders are received, baseline information communicated and initial visits made in a timely manner. Physician follow-up appointments are confirmed according to the discharge plan.