Coaching and Support so You Can Remain at Home

Lutheran Social Service of Minnesota offers coaching and support to assist patients for the first 30 days during a transition of care from a hospital or care facility back home. We are currently partnering with multiple hospitals and major health insurance partners.  

How it Works:

1. After discharge from the hospital, a specially trained and certified LSS community health worker (CHW) contacts the patient to let them know what to expect.
2. Within 72 hours of discharge notification, the CHW calls the patient to schedule visits by phone or in person.
3. During visits, the patient and CHW develop goals, review medications, conduct a home safety assessment, and discuss community resources, nutrition and upcoming medical appointments.
4. The CHW communicates consistently with the care coordinator throughout the service to ensure a safe and healthy transition.

Health Benefits for Patients:

• Stay healthy and independent.
• Remain at home and out of the hospital or emergency room.
• Receive social connection and ongoing support.  
• Feel safer at home.
• Learn new skills and get nutrition tips.
• Plan for medical appointments.
• Support to tackle challenges and make lifestyle changes.
• Gain a better understanding of medications.

Benefits for Care Coordinators:

• The CHW collaborates with you to support the patient.
• The CHW and patient work together to reach healthy goals.
• The CHW is your consistent eyes and ears in the home during the patient’s transition.
• The CHW saves you time by coordinating additional supplemental benefits and finding more resources for the patient.

Benefits for Health Care Partners:

• Customized to meet your needs.
• Fills the gap between hospital and home.
• Supports patients who are high utilizers of services.
• Option to add LSS Meals to Go frozen shipped meals.
• Customized outcome reports.
• Fall prevention support for patients.
• Encourages the use of primary care and other non-emergency services.
• Reduces hospital readmissions and lowers overall health care costs.

Proven Results

One of our LSS Healthy Transitions partners tracked claims data for individuals served in an 18-month period. They found that none of the 113 members had a subsequent inpatient admission within 90 days of hospital discharge.