Transitional care refers to the coordination and continuity of health care from one setting to another such as a transition from the hospital to your home. These transitions can take place between healthcare settings, or from a healthcare setting to a patient’s home. Older patients who suffer from a variety of health conditions often need health care services in different settings to meet their needs. The coordination and continuity of these services are essential for those with complex care needs and results in reduced hospital readmission’s.
After leaving a healthcare setting, many patients do not understand how to manage their health care conditions or whom to contact if their condition worsens. Poorly managed transitions can lead to physical and emotional stress, increased hospital readmission’s, and even death. During a transition, patients’ preferences or goals in one setting may not be passed on to the next setting, resulting in important elements of care falling through the cracks.
After leaving a healthcare setting, many patients do not understand how to manage their health care conditions or whom to contact if their condition worsens. Poorly managed transitions can lead to physical and emotional stress, increased hospital readmissions, and even death. During a transition, patients’ preferences or goals in one setting may not be passed on to the next setting, resulting in important elements of care falling through the cracks.
Ideally, every patient’s PCP would be responsible for the patient through every health care process, but this has been regarded as practically impossible. Therefore, more effort must be put into making transitions more effective. A major focus of the Q10 Protocol is to provide regular and consistent communication between all parties involved with a patient’s health.
Within 24-48 hours after discharge one of our Nurse Practitioners (NPs) will be in the patient’s home performing a reconciliation of all medications taken by the patient pre and post discharge. The NPs will review the discharge orders and perform a survey to determine that the patient and their living environment allows for the successful implementation of the POC (Plan of Care). The NPs communicate and coordinate with the PCP as long as the NPs are involved in the Transition Care Cycle which could be as long as 90 days. This type of medical attention to patients with high risk DRGs can make a significant impact in the health outcome.
