2021 DPSS Annual Report_FINAL

Annual Report 2020/2021

Adult Services

Collaborative Program Receives State Award In partnership with DPSS Adult Services, the Office on Aging’s Holistic Assessment, Resources & Transitions for Seniors (HARTS) program earned a Challenge Award from the California State Association of Counties (CSAC) in late 2020. 2. Professional nursing care follow up: Home visitation within 48 hours of client discharge to create a safety plan and ensure the client understands follow-up instructions.

3. Caregiver support: Establish homemaker services in cases where the client and/or their family faces new challenges that disrupt their daily life. 4. Medical Case Management (MCM): Provide medical, nutritional, social, and financial assistance. During the first 18 months of HARTS, 126 clients were referred to the program. About 45% of them (57 total) accepted MCM services. Of those 57 clients, 98% were able to manage their health care goals within three months after discharge while 89.5% were able to manage their treatment plans for at least 6 months after discharge.

Each year CSAC recognizes counties who are serving their residents in novel, efficient, and cost-effective ways. HARTS was one of 20 programs honored with a Challenge Award in 2020. The goal of HARTS is to increase positive health outcomes for hospitalized seniors with a history of abuse or neglect. Studies show that among vulnerable seniors 65 and older, hospital readmission within 30 days of discharge ranges from 12.5 to 16%. As a response to this problem, HARTS provides four critical services to seniors upon hospital admission:

1. Hospital transition: Immediate referral of APS client to a HARTS social worker.

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