When healing continues at home: AdventHealth partners with local organizations to support seniors

ORLANDO, Fla. - When Ofelia Mendoza left the hospital after a procedure, she knew she had more healing ahead of her. What she didn't know was how she would manage it on her own.

Mendoza, 73, lives alone in Mount Dora. Her car had been sitting for weeks and would not start, and she needed to travel to Orlando for follow-up appointments.

She also had been out of work while dealing with her health and was worried about being able to afford groceries.

"I don't know what I would've done without it."

"I didn't know how I was going to buy food," Mendoza said.

A connection made through AdventHealth East Orlando helped change that.

Mendoza was referred to Senior Resource Alliance, which connected her with community resources, including Meals on Wheels and transportation assistance.

Renacer Foundation, a community partner, provided hands-on support to help her navigate and access those services.

"The program is just wonderful," Mendoza said. "I don't know what I would've done without it."

Her experience is at the heart of a program that began as a pilot at AdventHealth East Orlando and has since expanded across AdventHealth's Central Florida Division.

The idea is simple: When a senior leaves the hospital, the care team looks beyond the medical needs that brought the person there and asks what might make recovering at home more difficult.

"There are definitely gaps sometimes that happen when patients leave the hospital."

"There are definitely gaps sometimes that happen when patients leave the hospital -- needs that we can't fulfill as inpatient employees," said Eryn Giammattei, a transition specialist social worker at AdventHealth East Orlando.

Those needs can be practical. A patient may need a ride to a follow-up appointment, help getting groceries or assistance with basic tasks at home. A caregiver may need a break. A senior may simply need someone to check in.

"When we can't fill those gaps and we're unable to provide those needs, SRA is there," Giammattei said.

The partnership grew from AdventHealth's Community Health Needs Assessment, which identified challenges facing older adults across Central Florida, including transportation, food insecurity and access to care.

Nicole Ayoub, chief nursing officer of care transitions for AdventHealth's Central Florida Division, said those needs are often closely connected to a senior's ability to remain independent.

"When we look at the seniors who suffer from heart failure, we also have to look beyond their health needs," Ayoub said. "We have to look at their transportation needs, what foods they may need, being able to have access to their pharmaceutical needs."

That is where the partnership begins to take shape.

With a patient's consent, AdventHealth care teams refer eligible seniors to Senior Resource Alliance, the area agency on aging for Central Florida, which helps identify what support is needed and connects the senior with community resources.

"The mission of Senior Resource Alliance is to serve seniors and their caregivers so they can age in place in Central Florida, in a community where they worship, they play, and they are close to the relatives and the people that they love," said Karla Radka, the organization's president and CEO.

From there, Renacer Foundation helps seniors put that support into practice during the 30 days after they leave the hospital.

Its team assists with needs such as transportation, food and household essentials while also connecting seniors with emotional or pastoral support.

For Henry Mendoza, chief operating officer of Renacer Foundation, the work often comes down to something very simple: being there.

"We try to be like their grandchildren," he said.

Renacer team members may accompany seniors to appointments, help them connect with resources or simply call to ask how they are doing.

Mendoza recalled one community health worker discovering a shared love of cooking with a senior and preparing a meal together.

"It helped them to be listened to, to do something that they really like," Mendoza said.

"At this age, you forget things."

For AdventHealth East Orlando patient Ofelia Mendoza, the help she received from her community support worker went beyond rides and meals.

"She makes sure she calls me every day. She makes sure I'm OK. She makes sure I have everything that I need," Mendoza said.

That same sense of support has helped another patient, Magdalena Tapias, 82, who lives alone.

The people helping her have assisted with meals, household tasks and medical appointments.

"It's so helpful to have someone keep track of my appointments and remind me when one is coming up," Tapias said in Spanish. "At this age, you forget things."

Giammattei said the support can also extend to caregivers. She recalled a patient who needed help bathing and getting dressed along with meals. Having someone come into the home gave the caregiver time to rest.

"If the caregiver is burnt out, then it's not going to be great care for the patient," Giammattei said. "So, we try to fill those needs with SRA out in the community so that the caregiver and the patient can get what they need."

At AdventHealth East Orlando, 122 patients have been referred through the program, with 108 approved for support.

The program now extends beyond its original pilot site.

Senior Resource Alliance currently supports patients in Orange, Seminole and Osceola counties, and AdventHealth has partnered with Elder Options to extend the effort into Lake County.

AdventHealth is tracking referrals and hospital readmissions and plans to add measures that look at whether patients' social needs were addressed during the 30-day program.

For Ayoub, the numbers matter because behind each referral is a person trying to get back to everyday life.

"What matters to many seniors is their independence," she said. "We acknowledge that, and it's an honor to care for them. We want to make sure they feel seen and heard."

For Mendoza, that support meant having food at home, getting to her appointments and knowing someone would call to check on her.

Sometimes, helping someone heal means making sure they don't have to figure it all out alone.