Transitions in Health Care: Who Is In the Driver Seat?

Health care reform has resulted in layoffs of 8100 jobs nationally last month.There will be more to come. This was not a projected or decidedly planned outcome of the Accountable Care Act, but understandable all the same.

Let me explain. Over the past 48 years since Medicare was enacted, health care organizations have been paid to treat people, the majority with Medicare as the payer. Costs have steadily to the point that it is one of the higher percentages of the US gross domestic product.


Healthcare has been big business. Hospitals and physicians have been rewarded for keeping the beds full and have been reimbursed well for the patients receiving treatment. Now under the current model of health care reform with the Affordable Care Act, healthcare is moving decidedly to a new model of care delivery. The new model of care delivery requires the patient to be accountable for implementing a plan prescribed and contracted with healthcare providers.

Health Care Reform is about placing the patient in the driver seat. It’s about attitude shifts of the professionals providing care. It’s also about attitude shifts among consumers receiving health care services. It’s about transitions in the processes of patient care delivery in all settings. Transitions are occurring on many levels. Transitions is the definite buzz word of the year, perhaps the decade.

Following new rules, a patient admitted to the hospital for a heart attack gets all of the appropriate treatment and success is measured by the outcome. Patients are being engaged and motivated to learn their care for better transition to the home setting. The hospital becomes accountable for providing high quality care, and setting up a solid foundation for a successful discharge. The patient is taught self-care for the heart condition to prevent more health problems before they are sent home and is given instructions for ongoing care that will be required.

The hospital is responsible to be sure the patient has an appointment with their doctor and other health care providers including Nurse practitioners and Physician Assistants. A patient who sees the health care provider for follow up within 7 days of hospital discharge does much better than a patient who cancels. Patients who know their medications and take them as scheduled are also found to be much more successful.

The litmus test is whether or not the patient stays well enough to remain out of the hospital. If that patient needs to be hospitalized again within 30 days, the hospital no longer receives a new payment for the second time hospital stay.

The patient returning home after a major event, like a heart attack, can now expect to have a “nurse navigator” contact her weekly for the first month or so after discharge from the hospital, perhaps even visit her once or twice at home. Nurse navigators make sure that the patient sees the primary care provider for follow up as scheduled, that she is taking all of the medication as prescribed, and is monitoring her blood pressure and sees the nutritionist to learn her heart-healthy diet as scheduled.

Not all patients can transition immediately to home. Older, frailer people or those who require the support and assistance of another to get safely out of the house after a hospital stay may go to rehabilitation facilities and or are referred to home health agencies to support the transition back home safely. Many need a rehabilitation hospital or skilled nursing facility stay for strengthening to improve their ability to care for themselves and require supportive skilled nursing services prior to returning home. This setting allows for additional coaching for successful self-care to occur and is an important step for many to prevent the inevitable fall and trip back to the emergency room if the patient went home immediately after discharge.

Patients can expect to find nurses and therapists continue with the care plan provided in the hospital aid in transitioning them into a successful home routine. Home care nurses and therapists case manage and encourage the patient to become and remain engaged in their care for full recovery. Patients need time to fully integrate the necessary lifestyle changes needed. Monitoring vital signs, continued teaching and support for adjustments to lifestyle following a heart attack assists the patient return to full physical function safely in her own environment are crucial steps for successful transitions home.

The transition path comes full circle back to the hospital for outpatient services for healthy heart classes and cardiac rehabilitation to support the patient in full recovery. The hospital is then rewarded for empty beds as opposed to the false assurance of full pocketbooks for people occupying the beds. Nurses and other health care professionals will find expanded roles beyond the walls of the hospital. Job opportunities will continue to evolve. In all settings, patient engagement and accountability is key. While health care looks different, costs will be controlled and ultimately the patient succeeds.


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