We have seen so many our Care Recipients lose so much of their recovery from the Acute environment to the home due to lack of a good transitional care process. By the time the medication, supplies and the therapy gets into place after discharge so much of what they have gained in their recovery is lost. This is just unacceptable to us so we have created our "Transitional Care Service"
Transitional Care Services have been the missing link in the continuity of care and is now becoming a standardized service as we start to transition from a "fee for service" to a "value of care" model health care system, building it around the Patient/Care Recipient.
This service will not only help make for a smooth transition to home but will be a huge part of preventing readmission's that ultimately provides better out comes from the overall quality of care, improving recovery time and reducing costs in the process over all.
Our Transition to Home Processes, the Transition Team, and how it all Works.
We assembled a "Transition Team" to bring the "Care Recipient" home
It is important to have a transitions team assembled to make these transitions successful for they come with various levels and degrees of needed care.
- We have established relationships with multiple Home Health Agencies and Hospice Companies, Geriatric Care Managers, Consulting Doctors, when skilled care is needed. in addition we have relationships with medical equipment and supplies companies along with local pharmacies.
- In most cases there will only be a need for just a Transitional Care Manager/RN to do things such as set–up/administer medications or things that non-skilled personal may need to be trained on. This will also allow the opportunity to educate and encourage the Patient to be more involved in their self-directed care assuring a higher success rate in their recovery.
Preparation of the transition:
- We first prepare for the discharge by working with the discharge department of the facility collecting the needed patient data: the diagnoses, care plan, doctors’ orders and instructions, medication list, supplies and equipment needed, important contacts, HIPPA release. This can all done by utilizing our simple one page transitions check list form to make sure we have everything we need to successfully take the patient home.
- At the same time we meet with the patient, family members and anyone that maybe involved the patients care.
- We then go out (if time allows) and do a home safety and aids inspection in preparation for the patient to come home. Utilizing our forms we do a home safety and aids check, double checking on what supplies, equipment and possible home modifications that are needed in order to bring the Care Recipient home.
- We then educate the care team and schedule the appropriate caregivers.
Discharge, the transition hand off
- We get the discharge planner to sign off on our transition form, double checking we have everything we need and then, unless other arrangements have been made pick up the patient and their personal items and transport them home.
- When they arrive home they are greeted with the care team (caregivers and family members) and they all go through our orientation from the Transitional Care Manager that includes the care plan, medications, and expectations.
- We then finish filling out our part of the transition form and send it back to the facility so they know that the transition was successful.
- Through our cloud based proprietary system all concerned stays in communication.
As a result the risks are reduced associated with readmission and the quality of care increases. Ultimately preventing the facility from readmission and cost per patient penalties with better patient retention.
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