Patients and FamiliesThe process of moving from one healthcare setting to home or to another provider is confusing for patients and caregivers. Medicare patients report greater dissatisfaction in discharge-related care than in any other aspect of care that CMS measures1. It is important for your safety to be knowledgeable about these areas before you leave the hospital:
1. Management of your medical (disease) condition
2. Purpose of your medications, and how to handle them appropriately
3. Follow-up with your physician to schedule an appointment within 72 hours of hospital discharge
Patients and caregivers will be interactive in their care through:
- Personal Health Record (PHR)
- Community Supports
EDUCATIONDescription: Teachings and materials targeted toward patients, family members and other informal caregivers on disease self-management, treatment options, medication management, expectations and available resources.
Aim: Enable patients to avoid unnecessary rehospitalizations though accurate understanding of self-care management after hospital discharge, and to have physician follow-up appointment within seven days post-discharge.
Targeted causes of readmission: Insufficient provider support to ensure patient and caregivers understand the importance of asking questions about and complying with the hospital discharge instructions.
Next Step in Care – Hospital to Home discharge guide for patients and families
Taking Care of Myself: A Guide for When I Leave the Hospital
Taking Care of Myself: A Guide for When I Leave the Hospital (Spanish Version)
Asthma Plan of Care
Heart Failure Plan of Care
Diabetes Plan of Care
COACHINGDescription: Coaching has successfully helped patients transition back into the community and improve patient self-management. Patients receive a pre- and post-discharge visit, along with a few phone calls, to reinforce self-care management skills. In a study using Eric Coleman Care Transition Interventions (CTI) a significant improvement was made hospital readmissions.
Aim: Empower patient and caregiver in achieving personal health goals. Prevents early hospital readmission.
Targeted drivers of readmission: Insufficient support for patient and family self-management, unable to understand and follow discharge instructions
Eric Coleman's Care Transition Intervention
PERSONAL HEALTH RECORD (PHR)Description: This patient centered record consists of important health information that must be shared to improve communication with your health care providers during the care transition. Print out the PHR, personalize it by filling in your information, and take it with you to all medical visits. Be sure to share the PHR with your doctors and nurses, asking them the questions you have written and updating them on any changes in your medications. This record is a living document that should go to all health care provider visits. You should update this record with each
Aim: Provide reliable resource for patients to document key medical information and track health support needs.
Targeted drivers of readmission: Insufficient support for patient and family self-management; poor information transfer.
Personal Health Record
Personal Health Record (Spanish Version)
COMMUNITY SUPPORTDescription: Connecting patients and family members to non-medical community health support agencies and other entities (individuals, community groups, businesses); patient use of resources provided by community agencies.
Aim: Eliminate everyday barriers to self-management (e.g., lack of transportation, ability to prepare good nutrition).
Targeted drivers of readmission: Insufficient home support for patient and family self-management.