Follow Up Care
Going Home. Now What?
One of the greatest challenges faced by patients and families is maintaining a patient’s health following their discharge to home. The statistics are alarming: nearly 18% of patients discharged from skilled nursing facilities in New Jersey need to be readmitted to a hospital within 30 days of their hospital discharge.
At South Mountain, we believe that having proper preventive systems in place can prevent most cases of post-discharge “falling through the cracks.” We have implemented the Ocean Healthcare Network signature Transitional Care Coordination Program to effectively eliminate these care gaps.
A SYSTEM THAT WORKS
Most incidences of preventable post-discharge complications fall into one of these categories:
- Medication complications
- Insufficient home health care
- Inadequate durable medical equipment
- Lack of follow-up physician/medical care
South Mountain effectively addresses these gaps at two distinct phases: the time of discharge, and after the patient is at home.
Care plan instruction
A nurse reviews all post-discharge instructions with patient and family member
Discharge planner educates patient and family about the series of follow-up calls they should expect to receive at home
A nurse schedules an in-home visit by an RN, who will reinforce medication reconciliation; perform an assessment to determine appropriateness of OT/PT; coordinate a therapy regimen; and arrange appropriate home health care.
Discharge planner orders Durable Medical Equipment and schedules timely delivery
Prescriptions are called in to patient’s pharmacy, with arrangements for timely delivery if needed.
Whenever possible, all patient’s medications are gathered: anything expired or irrelevant is discarded, and patient or caregiver is instructed on proper administration of appropriate meds.
Review of home environment to ensure it supports patient needs and goals.
A staff member schedules follow-up medical and diagnostic appointments including one with patient’s PCP approximately 1-2 weeks following discharge.
A designated Patient Care Navigator is assigned to each discharged patient. The Care Navigator is thoroughly oriented in each patient’s specific challenges, and is experienced with the various problems that can typically occur. The coordinator plays the crucial role of ensuring and reinforcing:
- Medication compliance
- Replenishment of medication supply
- Safety of home environment
- Procurement and proper use of DME
- Home Health Care in place
- Attendance of follow-up appointments
- Maintaining regular outpatient visits
- Adherence to health maintenance regimen
The Patient Care Navigator reaches out by phone at specific intervals following discharge to determine the status of each of these issues. These are not merely courtesy calls: if a ‘red flag’ is detected, the coordinator takes immediate and decisive action. This can include notifying the South Mountain nursing staff and patient’s physician; arranging medication delivery; proactively facilitating patient transportation to medical appointments; communicating with home health care agency or DME provider; and whatever measures are necessary to support patient’s health, safety, and successful outcomes.
By completing the circle and keeping patients connected with the relevant services and departments within their healthcare system, South Mountain helps close the care gaps and reduce avoidable readmissions.