Greetings!,
Being in the hospital can be a challenging time. As caregivers, we focus on making sure our patients and clients get the medical treatment they need while in the hospital. But it is also critical to consider next steps once they are ready to leave.
In the past few years, the healthcare industry has realized that proper care after a hospital stay is critical. In fact, studies have found that improvements in hospital discharge planning can dramatically improve patient outcomes as they move to the next level of care.* This is true whether patients are going home, entering a rehabilitation facility, or transitioning to a nursing home. And patients, family members, caregivers, and healthcare providers all have a role to play.
Cambridge Health Alliance has been working closely with community partners to improve the discharge process for our older adult patients. Dr. Rich Balaban, who is leading this effort, offers some expert advice on the transition from hospital to home.
After the Hospital Stay
Which patients need the most help in transitioning home from the hospital?
We know certain patients are at higher risk after discharge and need more comprehensive support during the transition home or to the next stage of care. They include:
- Older patients, especially those with complicated medical issues
- Patients with high risk diseases such as heart failure and COPD
- Patients with challenging psychiatric problems or substance abuse
- Those who have had hospital readmissions or ED visits within 30- days of a previous hospitalization
- Patients nearing the end of life
At CHA, we have developed care "bundles" to help patients transition from hospital-to-home. If you work with older adults in a post-acute facility or the community, you might be able to use some of this information to ask specific questions to help support the transition. What providers and caregivers need to know to support the post-hospital transition While the patient is in the inpatient setting: - Expected discharge date and time. This will help planning to support the return home.
- Medication reconciliation. What medication was a patient taking before hospitalization? The discharge medication list should identify which medications should be continued, which stopped, which changed, and which new ones to start. Can the patient obtain the medications they need?
- After-care needs. Inform the hospital of living arrangements. This will allow the staff to anticipate what type of support the patient needs at home.
- Written and verbal communication with patient and family. All patients and/or caregivers should leave the hospital with a clear understanding of the reason for the hospitalization, what they need to do to take care of themselves, and who to call if they need help.
After discharge: - Follow up call from primary care nurse, within 48 hours of discharge. A check-in with patients ensures they are taking medications properly, are aware of scheduled appointments, and have a chance to ask any questions or express concerns.
- Follow-up appointment within one week. To closely monitor medical issues, all patients need follow-up within 7 days with primary care or a relevant specialist. Post-discharge problems tend to occur early, so with sicker patients, follow-up often needs to be within 1-3 days.
- Partnering with special programs to provide enhanced home care. Patients may be able to get additional support after discharge from:
- VNAs
- Complex care management team
- CHA hospital-to-home program
- Community-based organizations
- Commonwealth Care Alliance
- PACE (Program of All inclusive care for the Elderly)
What else can I do to help? Here are a few important steps caregivers can take: - Make sure timely follow-up appointments are scheduled and attended.
- If you are a nurse, rehab specialist, nutritionist, or respiratory therapist - educate your patient with essential information.
- Physicians - ensure comprehensive medical management across the care continuum.
Effective discharge planning and transitional care is crucial in improving patient outcomes and lowering hospitalization rates. Thank you for working with CHA to support the health of your patients, members, or clients. * December 2007, Agency for Healthcare Research and Quality
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CAMBRIDGE HEALTH ALLIANCE is a vital and innovative community health system that provides essential services to Cambridge, Somerville, and Boston's metro-north communities. It includes three hospital campuses, a network of primary care and specialty practices, and the Cambridge Public Health Dept. CHA is a Harvard Medical School teaching affiliate and is also affiliated with Harvard School of Public Health, Harvard School of Dental Medicine, and Tufts University School of Medicine. For more information, visit www.challiance.org.
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This newsletter provides general information for educational purposes only. The information provided in this newsletter, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider.
Thank you.
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CHA in the News
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Patients and doctors sharing life stories can strengthen collaboration - CHA featured on WBUR.
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Watch the Health is Wealth TV Show
Everett, ECTV: Ch. 3 & 22 Tuesdays at 9:00 am and Thursdays at 7:00 pm.
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Upcoming Event
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Tuesday, February 3, 2015
12:30 - 2:00 pm
Bereavement Support Group - Learn new ways to understand your loss and meet your own personal needs
Connolly Senior Center
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CHA Malden Grand Re-Opening
Tuesday, February 24, 2015
3:30 - 6:00 pm
195 Canal Street
Malden, MA 02148
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Tuesday, February 24, 2015
1:00 pm
Topic: Anxiety
Cambridge Council on Aging
806 Massachusetts Avenue
Cambridge, MA 02139
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Wednesday, February 25, 2015
1:00 pm
Televised presentation on Nutrition - Eating the colors of the rainbow
Chelsea Senior Center
10 Riley Way
Chelsea, MA 02150
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Thursday, February 25, 2015
9:00 am
Alzheimer Partnership Meeting
10 Beacon Street
Somerville, MA 02143
2nd Fl Conference Room
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