TRANSITIONS Reduces Re-hospitalization

Hospitals are dangerous places for patients due to frequent medical errors. Almost 25% of all patients have an adverse event related to processes typically used to discharge a person home. A new program is helping avoid problems associated with discharge.

This innovative program includes a predischarge history and physical tailored to the special needs of geriatric patients, with emphasis placed on communication and teamwork among providers from different disciplines, a detailed medication review with a pharmacist, and a predischarge meeting among the patient, the patient’s caregiver, and a clinician.

The program was tested in general medicine wards run by hospitalists at 3 hospital centers in different states. At 3 days postdischarge, 88% of the study group described their health as better than it was before their hospital stay compared with 79% of those who did not have this process used as part of the discharge planning process.

Improving the transition from hospital to home with more information and better communication about care needs after discharge to home improves overall health. While this process is not used in all facilities at this time, Health Calls is implementing these services to assist patients In the transition to home. There are things that you can do to help your loved one in the hospital:

  • Visit frequently and ask questions about your loved one’s progress.
  • Keep notes about what is discussed.
  • Provide the doctor and staff with a list of the medications he/she was taking prior to hospitalization.
  • Review your loved one’s medical history with the clinical team. Ask about the current status of each medical condition.
  • Ask questions about signs or symptoms your loved one is experiencing in the hospital.
  • If you ask to speak to someone and no one comes to address your concerns within one hour, assertively ask to speak to someone again. If the doctor is unavailable ask to speak to the nursing supervisor or RN assigned to your loved one’s care.
  • Before discharge, ask for a printout of the list of medications that your loved one will be taking at home. Compare it with your list and determine any changes in the schedule. Ask questions about anything you do not understand.
  • Ask about any changes needed in your loved one’s diet, activity, or treatments.
  • Ask about your loved one’s ability to care for him or herself. Does he or she need help with walking or dressing, bathing safely? Medication management?
  • Request home therapy and nursing visits if there are any changes in his or her ability to care for self.
  • If he or she is unable to walk safely without help, consider a rehabilitation hospital or skilled nursing facility stay before returning home with home services.
  • Ask about follow-up care needed after discharge.
  • Ask for Health Calls Home Health Agency to reduce the risk for re-hospitalization. Health Calls Home Health Agency’s re-hospitalization rate is below the national average, ranking in the top 25 percent of all home health agency’s nationally.

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