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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 

 

 

 

Featured Service

 


February is American Heart Month! Are you at risk for heart disease?

 

The month of February is dedicated to raising awareness about heart disease and increasing knowledge about prevention.


 

Did you know that heart disease is the leading cause of death in the United States? Every year, 1 in 4 deaths are caused by heart disease. The good news? Heart disease can often be prevented when people make healthy choices and manage their health conditions.

 

Here are some quick tips for better heart health:

  • Work with your health care team.  Get a checkup at least once a year, even if you feel healthy. A doctor or nurse can check for conditions that put you at risk for heart disease, such as high blood pressure and diabetes.
  • Monitor your blood pressure.  Be sure to check this on a regular basis. You can check this at home, at a pharmacy, or at a doctor's office.
  • Get your cholesterol checked. Your health care team should test your cholesterol levels at least once every 5 years. 
  • Eat a healthy diet.  Choosing healthy meals can help you avoid heart disease and its complications. Limiting sodium in your diet can lower blood pressure. Be sure to eat plenty of fruits and vegetables.
  • Maintain a health weight.  Being overweight or obese can increase your risk of heart disease. 
  • Exercise regularly.  Physical activity can help you maintain a healthy weight and lower cholesterol and blood pressure.
  • Don't smoke.  Cigarette smoking greatly increases your risk for heart disease. 
  • Limit alcohol use.  Avoid drinking too much alcohol, which can increase your blood pressure.
  • Manage your diabetes.  If you have diabetes, monitor your blood sugar levels closely, and talk with your health care team about treatment options.

Learn about your risks for heart disease and stay "heart healthy" for yourself and your loved ones.


 

 

 

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.

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.


  

 

CHA in the News

Patients and doctors sharing life stories can strengthen collaboration - CHA featured on WBUR.

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