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Dr. Mark Toles studies gerontology at the UNC school of nursing. He developed a program called Connect Home which provides the tools caregivers need to help older adults with serious illnesses transition from skilled nursing facilities back to their homes.

“Transitional care are services and supports designed to help people as they transfer between settings of care,” Toles said. “For example, someone who goes from a hospital to home, like if they were in a hospital three or four days and then they were going straight back home.”

Toles said Connect Home began with trying to help nursing homes prepare patients to return home.

“The industry, at least the partners that I’ve worked with so far are very interested in providing high quality patient care. They’re doing as much as they can with a very high risk population to meet the needs of those patients.”

According to Dr. Toles, the move from a nursing home is a step-by-step process.

“The first step, we’re trying to make a really good assessment of what’s going on at home with that patient,” Dr. Toles said. “What’s happening with that caregiver and what kind of support does that patient and caregiver need to be successful at home?”

Reducing the number of patients who wind up back in the hospital is a big goal for Dr. Toles and Connect Home.

“We looked at the data for about 55,000 patients in North and South Carolina and in the process of doing that we saw that after about 90 days after discharge of high percentage of patients were back in the emergency department back in the hospital and some had died.

“So connect home was specifically designed to see if we could prevent some of those acute problems that we saw in the epidemiological data.”

Featured image via Sarah Daniels/Innovate Carolina