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Transition Teams Supporting Discharged Patients


Patricia Anderson suffered from a chronic illness. For months, her life was a continual cycle of falling in her home, calling 911, landing in the Emergency Room, being checked into the hospital, receiving treatment, and being sent home days later. The following week, paramedics would deliver her back to the ER.

Understanding this need for discharged patients to be prepared to care for themselves and have resources available to them once they arrive back home has resulted in a nationwide movement by hospitals to put transition teams in place. Some hospitals like Flagstaff Medical Center have been putting together transition teams for patients for several years – teams that include doctors, nurses, social workers, home health nurses and caretakers, pharmacists and family members.

But the emphasis on such programs will be even more critical next year when the Affordable Care Act kicks in, as hospitals will be penalized when Medicare patients are readmitted in less than 30 days from being discharged.

“When we send a patient home, we want to make sure it is safe. It is a high-risk time for a patient. They may be in a crisis situation with their health and we need to know how they are going to take care of themselves at home,” said FMC Care Coordination and Disease Management Director Lisa Brugh.

“A recent study of Medicare patients who were readmitted to the hospital in less than 30 days revealed that they are battling chronic illnesses and/or malnutrition,” said Brugh.

Several days before that patient is discharged, the FMC team works out a plan for him or her. The team makes sure the patient understands the diagnosis, any new medication and how it fits with other medications already being taken. The patient also is taught how to use new equipment such as oxygen tanks.

“We make sure they understand,” said Brugh. “In addition, we have taught our care providers ‘teach back,’ which is when we are done, we have the patient teach it back to us. We have a culturally diverse population and literacy is an issue. We make sure all of our materials given to the patients are culturally appropriate for them.”

The team also makes sure the patient has a primary care provider to understand the big picture, including whether there is support from the patient’s family, whether there is sufficient home health care, and whether the patient needs services from Meals on Wheels or hospice.

Priscilla Hardin’s situation is an example of how the transition team works. The 70-year-old Clarkdale woman spent two days at FMC for a hip replacement at the end of April. She lives alone and said she was a little nervous about being released, but she said she need not have worried. Before she left the hospital, she was given printed handouts about all her medicines and phone numbers for all her aftercare professionals, from in-home nursing to physical therapists.

“I felt if I had any questions, they would be answered because I could keep in touch with the home care people,” she said. “I am very pleased with my surgeon and the staff.”

“This is all about the patient,” Brugh said. “We are making sure our patients are keeping well and making sure they have the support they need. This is a good time to be in healthcare.” FBN














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