As healthcare providers, we understand the challenges and concerns that arise when patients are readmitted to the hospital shortly after discharge.
Extensive research indicates that breakdowns in care transitions are often responsible for these readmissions. At Preferred Care at Home, we have dedicated our efforts to addressing this issue head-on. We have developed tailored solutions for each of the six most commonly identified causes of readmissions. By focusing on seamless care transitions and providing comprehensive support, we aim to help patients stay home and avoid unnecessary hospital visits. Here are the reasons behind readmissions and how our services can make a difference:
Reason 1: Poor communication and collaboration during discharge between healthcare providers and patients/families.
Solution: Our Smooth-Transition Care program is designed to alleviate this problem. We provide a personal transition coach who acts as a translator, organizer, advocate, and companion. This dedicated coach assists the patient through the discharge process and provides support in the weeks following, ensuring effective communication and collaboration between all parties involved.
Reason 2: Medication errors and improper compliance.
Solution: Our transition coach ensures that medications are reconciled and all prescriptions are filled. They also arrange for pick-up or transportation when necessary. To further enhance medication management, patients receive our comprehensive Personal Health Record, a 15-piece tool kit that clearly organizes medication instructions and descriptions.
Reason 3: Failure to follow up with healthcare providers.
Solution: To prevent the risk of missed follow-up appointments, our Personal Health Record includes scheduled appointments in both print and secure online versions. Family members can access the online version, reducing the chances of a memory lapse. Additionally, our transition coach provides personal reminders and can even assist with transportation if needed.
Reason 4: No fall-prevention measures in the home.
Solution: Our transition coach conducts a thorough home assessment to identify potential fall hazards. They then work with patients and their families to create an environment that minimizes the risk of falls, making the home as safe as possible.
Reason 5: Lack of education about red flags with chronic illnesses.
Solution: The Personal Health Record includes an easy-to-read symptoms chart, which serves as a valuable resource for patients. This chart provides clear instructions on when to go to the emergency room and when to contact their healthcare provider. By empowering patients with this knowledge, we help them avoid unnecessary hospital visits and address potential health concerns promptly.
Reason 6: Health records aren’t easily accessible to the healthcare team.
Solution: Our online Personal Health Record ensures that crucial health information is readily available to all members of the healthcare team. With just a click and a password, authorized personnel can access recent tests, appointments, admissions, medications, and other essential information. This streamlined approach enables efficient collaboration and coordination of care.
We Begin Where Your Care Ends
At Preferred Care at Home, we go above and beyond traditional care services. Our transition coach continues to meet with patients on a weekly basis after discharge, providing ongoing support, encouragement, and accountability. They closely monitor the patient’s progress, ensuring early intervention in case of setbacks such as signs of depression.
We are committed to providing these exceptional services at an affordable cost to patients, without any expense to the healthcare facility. If you are interested in learning more about our affordable Smooth-Transition Care program and discussing how we can help you reduce readmissions, contact a location nearest you.
If you have questions about senior home
care services or if you want to start care:
March 25, 2016
Laurie Salmons, RN, BSN
January 9, 2015
Francesca Robinson, MA
August 27, 2013
Francesca Robinson, MA