The transfer of seniors from the hospital to home is when there is the greatest risk of error. Patients are being discharged from the hospital after shorter stays and as a result, they need more acute care at home. Patients and their families are now expected to accept greater responsibility for following doctor’s orders for care and rehabilitation at home. Miscommunication during transitions in care can result in important patient information not being handed off accurately, such as patient care plans and medication details. It can prevent all the parties, patient, hospital, caregiver, and provider from having a clear understanding of the patient’s prognosis, need for follow-up care, potential medication side effects and more.
Health care organizations around the world have spent time and money studying these “patient hand-offs” as they are called, with the goal of providing safe transitions. If you know the makings of an efficient patient hand-off you can help to ensure that your loved one gets home safely. As a caregiver, you can make sure that you have the information and support you need to provide accurate care.
A recent study1 on the issue of transitions identified current issues that may interfere with the smooth and safe transition of a patient from the hospital to the home setting.
- Problems accessing services
- Inability to understand and/or retain information about care
- Inadequate patient and caregiver education
- Limited continuity of care during transitions
- Lack of a care coordinator
- Inconsistent medical management
- Lack of timely follow-up
- Patients did not feel prepared to go home
- Multiple providers are not aware of current patient care, medications, and needs for services
- Family is not ready to assume care in the home
- Home health and support services are not in place
These are just some of the issues that make transitions a high-risk time for seniors.
However, a smooth transition that is well structured and prepares for effective communication can reduce patient risk and set the process in motion for successful care at home. A geriatric care manager can help seniors who are being discharged from the hospital, and their caregivers, experience seamless care.
The best transitions organize more frequent follow-up appointments with primary care physicians, social support, education for the family and caregivers and home health services. It also includes a plan of care, at-home health care providers who can assess the patient’s health and communication across all providers and health care settings. Perhaps most importantly, caregivers must have the knowledge and ability to care for the patient’s health, whether it is recovery from surgery or suffering with a chronic disease. The first 72 hours after discharge are critical. That is when services, medications, and home support must be in place
Geriatric care managers can support seamless transitions
Experts recognize the importance of including the caregiver into the seamless care plan and ensuring that they understand fully the plan of care and how to administer medications. However, that doesn’t always happen. Discharge education at the hospital may be lacking, language issues may interfere with full understanding, or the caregiver may be nervous about taking on the health care of a loved one. A geriatric care manager is trained to help make these transitions successful. They are professionals who will support the family and the caregiver with many services including:
- Making sure you understand all of the discharge instructions and service orders
- Setting up an in-home caregiver as needed
- Transporting the senior from the hospital
- Reconciling old and new medications with the physician
- Performing a home safety evaluation
- Confirming the senior has all the necessary home nursing and therapy services and equipment
- Schedule your follow-up doctor appointments
Clear, comprehensive communication between patients, their providers, and caregivers are essential if transitions in care are to be safe and successful for patients. A geriatric care manager can handle the details and then spend time with the senior, caregiver, and family to ensure that everyone understands what needs to occur to keep the senior safe and prevent them from being readmitted to the hospital.