Hospital-to-Home, Transitional & Postoperative Care

Many of the people in our care are trying to make a simple, safe and smooth transition from a healthcare facility like a hospital to their home.

Our non-medical care model includes services necessary to help patients transition safely out of a facility, including:

• Coordinating communication between providers
• Frequent follow-ups with families and discharge planners
• Medication reminders
• Transportation to doctor and allied-health appointments
• Preparing meals
• Running errands
• Keeping homes clean and safe 

What does the term “care transitions” mean?

The term “care transitions” refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

For example, in the course of an acute exacerbation of an illness, a patient might receive care from a General Practitioner (GP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where they would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition. 

Why are hospitals interested in care transitions programs?

Through healthcare reform and new initiatives, the federal government aspires to save billions of dollars in the coming years by leaning on hospitals to lower their preventable readmission rates. 

Care transitions programs allow hospitals to focus on reducing those numbers by improving the care coordination for patients between settings, which in turn lessens the likelihood that they will return for a related readmission. The core benefit of these programs for hospitals is that they are relatively low cost to implement and, if successful, they have the potential to produce a good return on investment (ROI) in terms of clinical and financial results.

What are some of the problems with the care continuum between healthcare settings?

Due to the infrastructure of our health care system, patients often encounter fragmented care when moving between healthcare settings.  Many elderly patients with chronic illnesses or conditions require care from more than one provider.

The following are some of the contributing outcomes of poor transition management: 

• There is often a misunderstanding or confusion on the part of the patients and their family caregivers about how and who should manage their care
• Medication errors involving misunderstanding of instructions, medication adherence and drug-drug interactions;
• Poor follow up with General Practitioner (GP)
• Lack of knowledge about alternatives (e.g. home care providers) in many communities

How are care transitions initiatives addressing these issues?

Confusion about care management – Patients are often confused about the discharge instructions set out by their care providers. Most elderly patients are contending with multiple chronic diseases/conditions and medications.  They are often readmitted for an adverse event within 30 days of discharge because they do not understand or did not follow instructions given to them. If there is no care coordination across settings, there is often conflicting and confusing information in the Care Plan or discharge instructions from different provider settings. 

In order to contend with these challenges, care transitions programs are empowering patients and their caregivers to advocate for themselves, since they are the constant thread through the care continuum. These programs are doing this by educating patients and equipping them with tools to manage their own care and prepare them for transfer to and from each setting.

Medication Errors – Care fragmentation impacts many aspects of the care continuum including patient safety. Medication errors account for many unnecessary readmissions to the hospital.

Poor follow up with GP – Another main cause for patients to be readmitted to hospitals is poor follow up with their GP. Frequently patients are scheduled for a follow-up visit after being discharged for a major procedure, such as heart surgery; however, they fail to make their appointment because they either forget about it, can’t drive themselves and/or do not have anyone that can take them. 

Alternate Solutions – While hospitals and healthcare professionals are beginning to understand and embrace the idea of better care coordination, they may not see the connection or need for alternative (non-medical) care providers. Hospitals have long seen the connection between discharge and home health settings but there is a void between those services and companion care. 

Many hospitals that are interested in improving care transitions are taking a community-based approach to care coordination.  

Who are the key players in community-based transitions programs?

To ensure a smooth transition across the care continuum, transitions of care typically involve multiple individuals across many settings. These individuals will include patients, family, health care professionals as well as non-medical community-based providers. While titles and responsibilities may vary from program to program there are three integral roles (in the hospital setting) that will be increasingly important in the development and execution of care transitions programs:

Case Manager – Registered Nurse responsible for providing patient assessment, treatment planning, health planning, health facilitation, and patient advocacy. 

Transition Coach – Typically a nurse or a social worker who works for the hospital or Long-Term Care Facility and designated by the program to prepare patients for what to expect in each setting and equips patients with the knowledge and tools required for successful self-management. In addition to transitions coaches, they may be referred to as; patient or care navigators, care intervention specialists, transitions care, coordinators, etc. 

Right at Home's Right Transitions Initiative

When you are discharged from the hospital, the effects of your condition aren't necessarily gone when you return home. This often makes it difficult when trying to adjust back to daily life. Most readmissions are preventable with a little extra attention and care. That's exactly what Right at Home's RightTransitions program offers.

Right at Home can provide services that allow you to get back on your feet and back to your life, including:

• Communication with family and healthcare providers
• Regular visits
• Medication reminders
• Transportation to doctor appointments
• Meal preparation
• Housework