Transitional Care/Care after a hospital stay
There is often a need for support at home, especially if a patient is recovering from surgery or from chemotherapy. They may need help conducting the basic functions of living, such as bathing, preparing meals, and doing chores.
During discharge, ask whether a case manager or social worker could help line up such assistance, possibly for a physical therapist or home health aide. It is also crucial to make an appointment with the patient’s primary care provider as soon as possible after discharge. The health care provider, whether a doctor or a nurse practitioner, can often help find other healthcare workers and services that help with personal care needs.
Primary care providers can play a crucial role in helping a patient make a smooth transition home from the hospital. A primary care provider can also provide referrals to home health care professionals if needed. Getting such help could prevent a patient from an ER visit or from being readmitted to the hospital. A patient’s health care provider at the hospital may have told you what the patient needs to do, but it often doesn’t register the first time you hear it, because everyone is dealing with so many things during a hospital release. There is no need to try to do it all yourself when trying to take care of yourself or a loved one. See a primary care provider as soon as you can, and don’t be afraid to ask for help if you need it.
Something that could alleviate some of the stress and confusion during this process is the Medical Home Concept.
The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving a child’s medical record. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed their own models for improving patient care called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006).
The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and it is a philosophy of healthcare delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination or end of care. It is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the best combination of services that best suits a patient's needs.
When being released from a medical facility, a bundle of discharge documents can include important information:
- a new prescription drug regimen,
- finding an inpatient or outpatient rehabilitation facility,
- keeping track of doctor's appointments,
- finding a specialist,
- purchasing any home medical devices and supplies
This kind of paperwork and activity can be overwhelming for anyone, especially immediately after release from the hospital.
Fully understanding discharge paperwork is one of the most common issues people face when they are making the transition home after a hospital stay. It can be overwhelming not only for elderly patients who have had surgery or other serious medical procedures but for younger individuals as well. If you are being discharged from a hospital, it is always a good idea to have someone with you during your discharge to take notes and ask questions.
If you are in pain or have questions, please give us a call at 832-915-2454 or schedule your appointment using our online scheduler.