Hospitals help patients with care transition after discharge

The transition from hospital to home after discharge can be problematic for patients – particularly those who are frail or elderly. Just because a person’s been cleared to go home doesn’t mean he or she is completely healed, or ready to be left alone. That’s why some facilities are taking extra steps to make sure patients are adjusting well after hospital stays. 

According to an article in Kaiser Health News, hospital-to-home programs have become more popular in a time where facilities are being held accountable for patient’s outcomes post-discharge.

One facility with a successful program in place is Palomar Medical Center in California. As discussed in the Kaiser Health News article, the hospital offers in-home transitional care for a month after discharge to older, eligible Medicare patients.

Benefits of program

Many factors can cause difficulty during periods of care transition for patients. Medications may not be taken properly, since patients and their families may be confused about dosage instructions after discharge. In addition, the patient’s caregiver (or the patient themselves) might not be clear on other requirements for their recovery at home, such as dressing changes.

These issues can cause complications that may require an additional hospital stay. Hospital-to-home programs attempt to keep that from happening by offering patients post-discharge support.

At Palomar, a nurse and a social worker visit the patient’s home shortly after discharge. They double-check that the patient is taking medications, making sure the person understands how and when to take them. Staff also go the extra mile, looking for anything in the home that could potentially harm a patient, such as fall hazards, and take patients through the steps to correct the issue.

In addition, they attempt to help patients solve any other problems that may be preventing them from getting the appropriate follow-up care, including lack of transportation or lack of communication with their primary care physician (or any routine care provider at all). The program helps connect them with resources so these problems don’t have a negative impact on their health.

Widespread success

Palomar Health’s hospital-to-home transitions program is part of a county-wide effort to improve outcomes for elderly hospitalized Medicare patients from four different health systems: Palomar, Scripps Health, Sharp HealthCare and the University of California, San Diego.

The goal of the county care-transition initiative was to help over 50,000 Medicare patients who were most likely to experience medical complications after discharge.

So far, the program’s been effective. In fact, it’s saved Medicare almost $14 million dollars in a two-year time frame, and most of these savings were due to decreased readmissions.

The program does have its limits. Right now, only certain at-risk Medicare patients are eligible, and patients only qualify if they’re being discharged to their homes instead of a skilled nursing facility. But for the patients it has helped, it’s made a big difference in their recovery.

Successful programs like these demonstrate why hospitals must start taking steps toward playing a more active role in patients’ care transitions after discharge.

Whether it’s following up on their adherence to their discharge plans or helping them coordinate appointments with primary care providers, facilities need to ensure patients are equipped with the resources and information they need to recover from their conditions.