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Tips from the other side of the hospital door
Transitions from the hospital go smoother and patients are less likely to be readmitted when the providers at the next level of care get detailed and complete information about the patient, says Sandy Merlino, RN, MBA, vice president, integrated delivery systems and hospital market development for Visiting Nurse Service of New York.
The Visiting Nurse Service of New York has partnered with New York City hospitals on ways to create smoother transitions and keep patients safe in the community. Here are some ideas from home health nurses on how hospital case managers can make transitions go better:
Inform clinicians in the next level of care when patients are at-risk for readmissions.
"We risk-stratify patients on our end, too, but we look at it a little differently. It helps to also have information on the patient’s medical history and what the case managers see in the hospital," Merlino says.
Make sure the providers at the next level of care have complete medication orders. Problems with medication are one of the big causes of readmission, Merlino says.
Before patients are discharged, find out if they have the ability to pay for the medication.
If not, work with the physician and pharmacist to put together a plan that will be realistic for the individual. "We get to the patient’s home and find out they don’t have their medication because they can’t pay for it," Merlino says.
Make sure that patients have a clear understanding of what their medication is for, how to take it, and the importance of taking exactly what the doctor ordered.
"We’ve encountered patients who found out that the friend or relative had the same prescription but weren’t taking it any more. So they were taking medication prescribed for someone else, even though the dosage might be different," she says.
Share information about the hospitalization with patients’ primary care providers.
When the home health nurses at the Visiting Nurse Service of New York check in with patients’ primary care providers, they often find out that the doctors are unaware that their patient has been hospitalized, she says.
Make sure patients have a follow-up appointment with their primary care physicians and inform the home health agency about the time, date, and provider.
"When it’s left up to the patient, they either don’t make the appointment or if they are told the doctor can’t see them for a month, they accept it. The physician office staff need to know that the patient has been hospitalized and needs to be evaluated by a primary care provider," she says.
Pass along information about family dynamics, she says.
"If it’s a big family, it helps us to know who is really in charge, who is the healthcare proxy, and who we can work with to resolve issues," she says.
Inform the home health agency if there is a psychosocial issue.
"We find that many patients who bounce back have a behavioral health disorder, depression, or anxiety. If we know about it, we can help them get help," she says.
Often, at-risk patients live alone with no support nearby and have no way to get their medication or get to a doctor’s appointment, she adds. If the home health nurse understands that there’s an issue or barrier up front, he or she can come up with a plan to overcome it.
• Include information in your report about how the patient was functioning before they were admitted and how it compares to their current functionality.
"An elderly couple may have been doing OK before the spouse was hospitalized, but they may not be managing so well after the acute care stay. We work with them to develop their goals and put together a plan to help them achieve the goals. If their goals are not realistic, we come up with a plan to help them see what is more realistic for them," Merlino says.
Early referrals result in the best transitions, especially if you collaborate with the home health agency liaison on the discharge plan.
Visiting Nurse Service of New York has nurse liaisons who go to the emergency department and the hospital units, attend rounds, and work closely with the case managers to develop a plan of care for patients at risk, she says.