Celene Livermore is the Community Care Coordinator at LifePath. She has served in this role since June 2023. “I have a background in Health Information Management (HIM) and was led to LifePath out of a desire to work directly in the community assisting those in need,” says Celene. She explains that her position is split between the Hospital to Home (H2H) program and additional roles within LifePath’s Information & Caregiver Resource Center (ICRC). Under the H2H program, she works at Baystate Franklin Medical Center and meets directly with patients during their hospital admissions to coordinate the initiation of LifePath services.
“Collaborating with the hospital case management team at Baystate Franklin Medical Center, I meet with patients and their families to educate them on the resources at LifePath. I submit referrals to our ICRC team for LifePath services and provide information on other community resources that may also be available to assist them. I stay connected with these patients and follow up with them post-discharge to ensure they are receiving the help they need with the ultimate goal of preventing readmissions to the hospital,” says Celene, who thanks “Jennifer McCready, Baystate Regional Manager of Case Management; Lisa Kingsbury, Baystate Quality and Case Management Coordinator; and the entire BFMC Case Management team, who have all been incredibly welcoming and gracious towards me since my start.”
In Franklin County in particular, this type of program is reaching a population of consumers who are underserved and may be discharged from the hospital with little or no resources.
The H2H program meets patients where they are. In Franklin County in particular, this type of program is reaching a population of consumers who are underserved and may be discharged from the hospital with little or no resources. It is reassuring to the hospital care teams to know their patients are being directly met with services they so desperately need.
“With the follow-up process, I am able to stay connected with patients, which I’ve noticed has helped them stay motivated to take the precautions necessary to prevent further decline in their health. This type of positive reinforcement fosters a sense of empowerment and resilience. For consumers that are already enrolled in LifePath services, the H2H program allows for better coordination and communication between LifePath and Baystate. Many times, I am able to create conversation between case managers from both sites, which has many benefits in terms of overall patient care,” states Celene.
One example of how the H2H program can help is the case of an 82-year-old resident of Greenfield who arrived at Baystate Franklin Medical Center in February after experiencing persistent vertigo and aphasia. This was her third visit to the hospital with similar symptoms in a six-month timeframe. They found out she lived independently and her primary support was her daughter who stayed as involved as possible but lived out of state. When Celene first met with this individual and her daughter, she discussed a variety of LifePath services. Neither the individual nor her daughter thought these services would be necessary, so Celene said she would follow-up via phone in 2 weeks and then a month’s time, per program guidelines.
By the time Celene made her first follow-up call two weeks later, the individual had realized she needed some support, and referrals were made for Meals on Wheels and Home Care. Once these programs began working with her, her case manager set up a delivery for a cane to better ambulate around her home, as well as a HERO medication dispensing machine to assist with medication management. Since the February hospital admission, this individual has not had any readmissions.
The Hospital to Home Partnership Program is a two-year grant program between hospitals and Aging Services Access Points to strengthen communication and coordination with community providers. LifePath and another area ASAP, Greater Springfield Senior Services, have partnered with Baystate Health for the Hospital to Home Partnership Program.
