When an older adult transitions from home to hospital to nursing home, they often feel a loss of independence, choice, good health, identity, security, and belongings. The person’s world may be turned upside down, they may fear the unknown, and they may not know where to start again. Community Living Specialists offer transitional support in bridging the gaps between nursing home and community living.
Pam Will, LSW, sees every person and situation as unique. As one of MAAA’s Community Living Specialists, Pam works with older adults to return home after a stay in long-term care. She gains a good understanding of what a person hopes to achieve and then provides them with the tools to succeed. Charles is a typical example of the consumer Pam encounters. When she first met Charles in a nursing home, he had been there 97 days and was determined to go home. Charles looked to Pam for support and resources. She said, “I think he immediately saw that I could be an advocate and a source of information for him.”
After returning home, Charles fell, was hospitalized, and again placed in the nursing home. Pam visited Charles and immediately recognized his frustration with loss of control. “Charles never gave up the belief that he knew what would be best for him, and he never gave up his resolve to return to his home.” With guidance from Pam and connections to community resources, Charles soon began a “new normal” life at home with his wife.
Taking a person-centered community support approach in meeting an older adult’s independence goals is the foundation of the Return to Community initiative, a state-funded program of the Senior LinkAge Line®. Watch this video to learn more about Charles and the Return to Community program.