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Director's Message

May 2013 - Navigating a Changing HealthCare Landscape

How do you know how to navigate the complex healthcare and support service systems? How do you evaluate the options given to you?

 Increasingly, patients are expected to manage their own medical and support care. But it can be overwhelming and confusing. PSRC is expanding our resource services through PIC Princetonsm to help you get the care you need.

Health care has evolved dramatically over recent decades and now the Affordable Care Act is initiating several changes. Procedures that once kept you in the hospital for days or weeks are now done in outpatient surgery, sending you home the same day. Techniques like laser surgery have transformed medicine, and studies show that it’s better to get moving again quickly and to get away from potentially life-threatening infections that can be acquired in the hospital. Research also illustrates that there are significant cost savings with home-based care. But this also means that you come home in a more fragile condition needing more care. This can be problematic if you don’t have a support system to care for you.

Studies indicate that many people do not follow the recommendations for follow-up treatment, leading to further complications and re-hospitalization. The Federal government (through the ACA) is piloting several initiatives to improve outcomes and reduce costs to Medicare and Medicaid.

Often a person also needs non-medical services such as transportation, meals, and homecare. Where do you start when you hear “your family member can no longer be left alone?” Or you may need to explore whether there are assistance benefits that will help pay for care.
Hospitals have discharge planners, once social workers but now often nurses, who set up the transfer to rehabilitation or skilled care, and make sure that you have the doctor’s recommendations, appointments and prescriptions. But they don’t follow up to see if you met these recommendations.

Several hospitals, including Princeton HealthCare, have initiated a new care transitions program, where a transitions coach meets with a patient once or twice before and after discharge to ensure that you understand and can follow the recommendations. This is a short-term relationship focused on a single episode and diagnosis. It is critical that there be a smooth transition from hospital doctors, treatments and medications to outpatient care. Hospitals that experience fewer readmissions will be rewarded financially.

Now that there is so much emphasis on home-based care, there are a growing number of options for case management or care coordination. There are so many medical and social services that you may use, usually with different providers, which takes a lot of coordination. Your needs are likely to change over time, so frequent adjustments need to be made. A professional navigator knows the area resources and how to access them, as well as being aware of factors you may not have thought of.

Here are some of your options:
Care Coordinators –social workers who do an assessment, action plan, and provide an ongoing follow-up relationship. We work with many other medical and social service providers to create a comprehensive network of services to meet your needs.

Geriatric Care Managers –professional social workers and nurses who assess, plan and coordinate care. They are available 24/7 and many will accompany you to appointments. Some businesses provide additional services themselves (such as homecare).


· Homecare Agencies –Many homecare agencies are now stating they include care coordination as an ancillary service if you are using their home health services.


· Physician’s Offices – Some medical groups are now including care managers for their frail clients who have complex medical conditions. Medicare is rewarding practices for reducing costs for these patients.


I recently met with a couple who had been through a hospitalization and follow-up care. As they navigated through the system, they met with many of the services listed above. It was apparent that it could be confusing to sort out all these coordinators, especially if one gets conflicting recommendations. So how do you decide what is right for you?


Some questions that may help you decide:

Would it be helpful to have someone to guide you?

Do you need help for a single incident or want ongoing support?

Do you need to have someone available 24/7?

What are the person’s credentials and length of experience? Do they belong to professional organizations?

Is care coordination the primary work of the organization?

What are the initial and ongoing costs?

Do you trust and feel comfortable with this person?

Is the person there when you need them?


The decision between these services may depend on how much and what kind of support you need/want and your financial resources. I strongly recommend having a care coordinator or care manager if you do not have supportive family members nearby.


Discharge planners and care transitions coaches are short-term and focus on a single episode of


care, tending to focus on the medical issues. A care coordinator or case manager will build an ongoing relationship with you regardless of where you are living or receiving care. They look at the larger picture of your resources and needs on many dimensions and can coordinate both medical and other support services. They are very knowledgeable about housing options, homecare, resources and medical care. They can connect with discharge planners, residential community staff, transitions coaches and family at a distance.


PSRC’s PIC Princeton program provides care coordination. We will work with you, your family and any other medical or service providers to ensure seamless transitions and comprehensive, coordinated care with good communication. We build long-term relationships so that we will know you and your support system so we can help when you need it.


Because of the new Federal incentives, the array of home and community services will continue to grow and become more complex. If it is confirmed that home-based care is more cost-effective, and as more people live longer at home with chronic conditions, more of the care coordination and direct care will fall to family caregivers. Call if you want to discuss your options or learn more about PIC Princeton.

Susan W. Hoskins LCSW



Previous Messages

October 2017: HomeFriends Celebrates 30 Years!

September 2017: Annual Report

July/August 2017: Preferred Caregivers: Daughters

June 2017: Cues & Clues

May 2017: Recharging

April 2017: GrandPals Celebrate 20 Years!

March 2017: Multi-generational Households

February 2017: No One Ages Well Alone

January 2017: Help at Home

December 2016: Gratitude

November 2016: Family Caregiving

October 2016: Annual Report

September 2016: Corporate Healthcare

July/ August 2016: Strategic Planning

June 2016: Is Your Home Age- Friendly?

May 2016 Part 2 : We Need Your Help

May 2016 Part 1: Going Solo

April 2016: Volunteering

March 2016: Partners In Caring

February 2016: PSRC's Strategic Plan

January 2016: Hope

December 2015: Gratitude

November 2015: Helicopter Children

October 2015: Is Princeton An Age Friendly Community?

September 2015: Annual Report

July & August 2015: Family and Community

June 2015: A Gift that Keeps Giving

May 2015: Is 60 the New 40

April 2015: Spring

March 2015: On Being Mortal

February 2015: Mentoring

January 2015: Winter Blues

December 2014 - Leaving A Legacy

October 2014 An Age Friendly Future

September 2014 Annual Report

July - August 2014

June 2014 - Romance After 50

May 2014 - Your Virtual Estate

April 2014 - Memory and Forgetting

March 2014 - Aging in Community

Observational Stay

February 2014 - Family Caregiving

January 2014: Attitudes about Aging

December 2013 - Giving

November 2013 - Healthcare Marketplace

October 2013 - Annual Report 2013

September 2013 - Total Brain Health® Fair

July - August 2013 My cat, My Father and Me

June 2013 - Age Friendly Communities

May 2013 - Navigating a Changing HealthCare Landscape

April 2013 - Becoming Visible

March 2013 - Navigating Life’s Transitions

February 2013 - Partners in Caring Princeton

January 2013 - Men as Caregivers

December 2012 - The Safety Net

November 2012 - Going Solo

October 2012 - Documenting Your History

September 2012 - A Journey of Transformation

July - August 2012 - Gratitude & Moving

June 2012 - Diversity

May 2012- Aging in America


March 2012 - Patient-centered Care

February 2012 - Can you Spare an Hour?

January 2012 - Challenges & Opportunities

December - Are you Prepared for Emergencies?

November - We need YOU!

October - Chocolate for Memory

September- Looking Back and Looking Forward

July - August 2011; Ageism

June 2011 - Accessibility

May 2011 - Paper retention

Knit Wits, April 2011

Lessons and Legacies, March 2011

Independent Living February 2011

Home Safety January 2011

Witness to my Life December 2010

Elections, benefits and open enrollment November 2010

Retire in 3D!

Strategic Planning September 2010

Am I Old? July 2010

Memory Clutter June 2010

Aging In America May 2010

Volunteering April 2010

Spirituality March 2010

Estate Planning February 2010

Encore Careers January 2010

Hiring Home Care December 2009

Annual Giving by Sharon Naeole November 2009

Flu Pandemic 2009 October 2009

Healthy Memory, Healthy Mind September 2009

A Personal Perspective on Caregiving July/August 2009


Wei Ji: Crisis, Danger and Opportunity April 2009

Write your own obituary March 2009

Hobbies February 2009

Hope and Vision in Challenging Times
January 2009

Medicare Changes 2008: Take A Look! December 2008

Scams, Frauds and Rip-offs November 2008

Engaged Retirement: Beyond Financial Planning October 2008

September 2008 Caregiver Dilemmas

Finding Rhythm and Purpose July/August 2008

Spring Cleaning II June 2008

V + OA = ER (Volunteering + Older Americans=Engaged Retirement)May 2008

Spring Cleaning April 2008

Have You Had the Talk Yet? March 2008

Get Moving with FitRhythms™! February 2008

My Condolences January 2008

Advocacy December 2007

What Are Social Services? November 2007

Sensitive Topics October 2007

Plan for the Future September 2007

The Up-side of Aging Summer 2007

Volunteering June 2007

Strategic Plan May 2007

National Conference on Aging: Let's ReThink Aging April 2007

Brain Health March 2007

Resiliency February 2007

Transportation January 2007

Season of Giving December 2006

Medicare Part D November 2006

April Hill McElroy October 2006

Civic Engagement September 2006

Change June 2006

White House Conference on Aging May 2006

Hearing Loss April 2006

GrandPals March 2006

Lets Talk February 2006

Eldertopia January 2006

Hoarding December 2005

Annual Report: November 2005

Are You Prepared? October 2005

Planning Ahead October 2005

Watch Your Language September 2005

Medicare Part D Summer 2005

Sue Tillett June 2005

The End of the Journey May 2005

Clutter March 2005

New Dietary Guidelines February 2005

Transitions January 2005

Funding December 2004

Caregiving November 2004

Civic Engagement with GrandPals October 2004

A New Look September 2004

Safe Driving Summer 2004

Food Safety June 2004

Communication June 2004

The Challenge of Giving Care May 2004

Seniors On The Move April 2004

Depression March 2004

McGreevey February 2004

Medications January 2004

Random Acts of Kindness December 2003

Civic Engagement November 2003

Reverse Mortgages Oct 2003

Emergency Preparedness, Jan 2003

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