Continuum of care for smooth transition

Team Effort

Pictured (from left) are Vicky Groce, CNO, LCHS; Barbara Merrell, social worker for Donalson Skilled Facility; Susie Compton, administrator, Lincoln Medical Home Health & Hospice; Angie Sellers, case manager, Lincoln Medical Center; and Gloria Meadows, administrator, Patrick Rehab and Wellness Center.

Editor’s Note: The following is the fourth and final article in a series focusing on National Home Care and Hospice Month.

Along with other services, Home Care can be a very important component in a patient’s recovery after a hospitalization.

Regardless of how you cast your vote on Nov. 6, you will be impacted by the changes in health care that have already occurred and those that are on the horizon. The Centers for Medicare and Medicaid Services (CMS) is implementing interventions aimed to improve care and lower costs for Medicare beneficiaries. Keeping patients at home after a hospitalization is an area of particular importance.

Starting October 1, 2012, Medicare began fining hospitals that readmit too many Medicare patients for complications within 30 days of being discharged from the hospital. The fines will at first apply to patients readmitted for heart attacks, heart failure and pneumonia, but Medicare is considering imposing fines related to other diagnoses in the future. Nationwide about two-thirds of hospitals that serve Medicare patients will be hit with penalties.

Recent studies indicate that readmissions occur more often with certain diagnoses and procedures, and are frequently caused by:

·                Medication errors: The patient lacks instruction on a new prescription or has difficulty getting it filled, or the new prescription may interfere with existing medication. In some cases, the patient is taking new medications prescribed during hospitalization, and continues medications he or she was taking at home before the hospitalization and the patient’s regular physician may not be aware of all of the medications the patient is taking.

·                Inadequate discharge planning: The patient receives little or no information on how to achieve a successful recovery and/or does not schedule a follow-up appointment with their physician. Having a follow up appointment with the primary care physician within 7 to 10 days of discharge has been linked to improved outcomes after a hospitalization.

·                Inadequate post-discharge arrangements:  Family members or caregivers are uninformed or unable to provide the necessary care for transitioning the patient from the hospital to the home. Perhaps they don’t have adequate supplies at home, or are unable to be present to assist the newly discharged patient, who may not be ready to be alone and manage his or her own care. In some situations, the patient cannot or will not comply with the care that is necessary to prevent a re-hospitalization.

·                Inadequate communication: Delays of the hospital physician providing a discharge summary to the patient’s physician can result in a patient’s “home” physician never being aware that the patient was in the hospital. Another communication issue impacting a patient’s ability to remain at home following a hospital stay is not ensuring the patient understands the discharge teaching. Patients may leave the hospital with armloads of directions, instructions, and other information, but if they don’t understand or are unable to do what is necessary to recover from a hospital stay, then readmission is a real possibility.

Hospitals nationwide are reviewing their processes in an effort to decrease or avoid readmissions.

“Currently, Lincoln Medical Center’s readmission rate falls below the threshold for any penalties to be imposed,” said Vicky Groce, Chief Nursing Officer of Lincoln County Health System. “The Health System is focused on making sure readmissions don’t become a problem, and various departments have been working together to improve the discharge process for patients.

“For example, department managers in the Medical Surgical area, Intensive Care, Home Health, and Dietary collaborated on discharge teaching booklets for patients with heart failure, lung disease and diabetes as an effort to streamline the education provided to patients with those diagnoses at the Medical Center, in Home Health, and at Donalson Skilled Nursing Facility.”

Angie Sellers, RN, case manager with Lincoln Medical Center, explained, “We strive to provide discharge planning and teaching to make sure that patients have the necessary follow up appointments with their physicians, have the resources they need at home, and that they understand what they need to do when they get home to recover. We also work with our hospitalists and local physicians to ensure that patients’ physicians are informed of their hospital stay and plans post-discharge.

“Whether the patient is going straight home to recover, is able to go home with outpatient rehabilitation at the Patrick Rehab-Wellness Center, or needs continued care in a skilled nursing facility, we look at the patient as a whole when determining the best options for care after discharge.”

Some patients can truly benefit from a period of time in a skilled nursing facility prior to returning home after an operation or illness.

“Short-term skilled care is designed for patients who are recovering from a recent acute illness and need short-term care before returning home,” explained Barbara Merrell, social worker for Donalson Skilled Nursing Facility. “These patients may benefit from daily physical, occupational and speech therapy. A short stay may also be necessary to complete intravenous antibiotics. A complex medical condition may require a long-term skilled care stay.”

For some patients, a smooth transition home may include the skilled support of home health nurses and therapists.

“For patients who are homebound, home health intervention can enable more patients to remain out of the hospital following an initial admission, or prevent avoidable hospitalizations all together,” said Susie Compton, RN, administrator of Lincoln Medical Home Health and Hospice.

“Nurses are able to work closely with discharged patients and families to ensure that medications are correct and that the patient has an appointment with his or her primary care physician for follow up. Therapists can provide instruction in home exercise programs and various treatments to assist in continued recovery. Staff can also monitor patients via telehealth and facilitate communication between the patient and physician to catch problems early and intervene appropriately.”

“We are very fortunate to have the variety of services that we have within Lincoln County Health System,” stated Groce. “Individuals representing different areas of health care are able to collaborate on best practice interventions for problems like readmission. This really does allow us to improve health care delivery in our community.”

Posted on Tuesday, November 27, 2012 at 12:02 am