What is Project Independence?
Project Independence is a program of trained volunteers who, under the supervision of a public health nurse case manager, serve as caring partners to build a bridge of advocacy and support for persons who are transitioning from hospital discharge to independence at home.
Since 2001, volunteers have provided watchful guidance, helpful resources, supportive companionship and health education for frail, isolated persons in the community who are in most need of this partnership – the Project Independence volunteers’ mantra is “to see what needs doing – and do it!” Volunteers’ help patients understand and follow through with their discharge plan: making sure they understand their medication orders and provide links for support as needed, including home health care, home-delivered meals, social and financial benefit programs, companionship and transportation.
If you want to make a real difference in people’s lives, call us today: 473-2836. Or click here to send us a message.
Why Project Independence was created
After hearing from local hospital and skilled nursing facility case managers and discharge planners as well as community residents recently discharged from a hospital stay, it became apparent that significant service gaps existed between hospital and home for a specific population of frail, isolated, health-challenged individuals. Days passed before home health care was in place, medications were not readily available and these most vulnerable patients were unable to comprehend, much less manage, their discharge plans. This group had an exceedingly high ‘bounce-back’ rate where on average 15% or more were re-admitted to the hospital within 30 days for complications and/or failure to thrive.
In an effort to address this threat to the health and wellness of many in our community, a plan was formulated with the idea that a trained volunteer could be partnered with an individual patient upon discharge from the hospital. The Division of Aging applied for and received a Long Term Care Innovation Grant from the California Department of Aging. This 18 month long grant was one of 28 Innovation Grants awarded throughout the state early in 2001.
Over the course of six years, over one thousand patients have been served by Project Independence. Both the program and the patients in need have a resource to support them in a strong transition from hospital to home. The results have served to enhance convalescence and prevent both nursing home placements and hospital re-admissions.
“It was such a relief to learn about Project Independence. In today’s world, with family members often spread out far and wide, the services provided by Project Independence’ staff and volunteers were vital for my aunt.”
Family Member
How Project Independence Works
Hospital case managers from all four area hospitals identify and refer patients, eighteen years of age and older who are isolated, lacking family or community support and who find it difficult to manage their hospital discharge plans. When the Project Independence Public Health Nurse Case Manager has ascertained the specifics of an individual’s needs, either during a pre-discharge hospital or in home visit, a trained volunteer is then assigned to manage an approximately eight week plan of assistance.
Both the plan and the presence of a focused and dedicated volunteer are the keys to a safe and effective transition from the hospital to independence at home. Volunteers are cleared through the Marin County Sheriff’s office using ‘Livescan’ and ongoing training and supervision is provided by Rita Widergren, nursing director of Project Independence. Volunteer advocates will visit program participants in their homes and support them in understanding and following through with their discharge plans.
Volunteers support the patient in providing the transportation needed to get back to their doctors for post-hospital follow-up or physical therapy or dialysis treatments. They also coordinate and arrange for such services as shopping, home delivered meals, medication support, social and financial resources, public benefit programs and home health care. Indeed, Project Independence provides the caring partner who will see what needs doing and do it!
Our results: the national average for hospital readmissions within 30 days is 25%. The Project Independence average: 6%
The volunteers and staff of Project Independence have enabled our clients to return to their homes by providing a “bridge” of services in coordination with what our programs are able to do for them. These clients are now stable and can remain in their own homes.
Linkages Case Manager
Future Planning
What we’ve learned: the vital need for a safety net in the post-discharge transitional stage and how Rita Widergren, Project Independence’ outstanding leader and her dedication to the “people we are privileged to serve” and her inspiration to the volunteers is an essential component of PI’s success.
In response to changing health care trends and utilizing the same volunteer advocate model PI has incorporated the following additions:
“Hawkeyes”: same day surgery transportation program that partners a volunteer with a patient to ensure their safe transition home.
“Marin Moves” links to local transportation resources (primarily free and low-cost).
“Bridges”: a quarterly dialogue among health care providers to address issues and support continuity of care.
“Healthy Living Workshops” – for those patients who have transitioned from Project Indenpence, we offer a six week chronic disease self-management program. Healthy Living Workshops are based on the Stanford University Lorig model of Chronic Disease Self-Management and are led by trained volunteers.
“Healthy Housing” –applying the Project Independence model upstream in residential facilities for disabled and low income seniors, in partnership with Public Health Nursing and CAPA, the Healthy Housing goal is to prevent social isolation by providing health education, services and support which mitigates functional decline.
“Collaborative Academic Practice Alliance [CAPA]: linking academic and public health nurses in practice.
For the past five years, Project Independence has partnered with local nursing schools, including USF, UCSF, San Francisco State and Dominican University under the auspices of Public Health Nursing, Department of Health & Human Services, whereby student nurses, occupational therapy students and physical therapy students who are in their community health rotations are able to provide further health monitoring and education to those who have transitioned from the PI program.
The Future of Project Independence
Project Independence has been extremely fortunate both in the quality and commitment of its volunteers as well as continued community support both from the Marin Board of Supervisors and the Marin Community Foundation, a consortium of area hospitals as well as the Marin County Commission on Aging. Many of our volunteers are bi-lingual, representing, among others, Spanish, Farsi, Chinese and Vietnamese speakers. Our patient coverage includes the entire county, from Marin City to the rural areas of West Marin. In a County that is among the grayest in California – 13% of our population is over 65 –Project Independence continues to make a difference.
If you want to make a real difference in people’s lives, call us today: 473-2836. Or click here to send us a message.
As far as we are concerned, Project Independence flew in on angel wings.
Hospital Discharge Planner
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