Back | Benefits of Transitions of Care Management | Frequently Asked Questions
Emphasis on Patient and Caregiver Education
Patients often retain little of what they are taught while hospitalized. A great deal of information is communicated to patients and family members during hospital stays, but often the patient and caregivers are unable to absorb that information because being in the hospital is such a stressful and vulnerable experience. A key element of our service is the priority on patient and family education both in the hospital and in the transition from hospital to home. For example, in the first post-discharge visit the Clinician devotes significant time to reviewing the hospital discharge instructions to ensure that the patient really understands and can execute the plan of care. Emphasis is placed on “translating” information to ensure that each patient really understands what is being communicated.
In-Hospital Visits with Patients.
Our Clinician will conduct a comprehensive assessment of the patient’s health status and define priority needs and services for the patient and family caregiver(s). The Clinician collaborates with the Physicians and other members of the health care team to streamline the plan of care and to design and coordinate inpatient and follow-up care based on the comprehensive assessment and goals identified for the patient.
Home Visits with Patients.
The quality and amount of information derived from being in patients’ homes and seeing them function in their own environment cannot be under emphasized. Through home visits, our Clinicians get to see firsthand how patients are managing their medications, their home environment, and the interaction between their environment and their health (e.g., the presence of mold in the apartment of a COPD patient; plants that could cause allergies; stressful living conditions). These frequent and repeated opportunities to gather patient and family caregiver information, conduct ongoing assessments, provide teaching and patient/family education, and to reinforce healthy behaviors are ingredients for quality outcomes.
Coordination with Primary Care Physicians, Specialists and other Providers
Our Clinician contacts each patient’s Physicians to let him or her know that the patient is receiving care through us. We will work with these Physicians as the medical plan of care is developed and implemented. Throughout the certification period, we update each patient’s Physicians on the progress he/she has made.
Whenever necessary, we will facilitate access to palliative care or hospice services, assisted living, or chronic case management, based on the individualized needs of patients and their family caregivers.
Medication Reconciliation and Management
Upon admission to our care, our Clinicians review the medication plan for contraindications and unsafe interactions. The Clinicians perform medication reconciliation to assure the correct medications, in the correct doses, are documented in the patient’s medical record and present in the home. Patient understanding of changes in medication dosing, brand versus generic names, and adherence with medications is a priority. The Clinician instructs the patient about each medication stressing its rationale, schedule, side effects, dose in strength and number, and storage. The Clinician assesses the patient’s current system for managing medication and obtaining refills, and suggests changes to medication behavior as needed (e.g., obtaining pill planners, 90 day supply ordering). Each patient’s ability to afford co-payments is assessed, issues surrounding prescription coverage and formulary restrictions are identified, and suggestions for changes to the medication plan, based on coverage, are discussed with all Physicians involved.