By: Members of the SoNE HEALTH Population Health Team
Have you ever participated in a relay race, focused on handing over the baton, to get to the finish line? Experiencing time in the hospital or emergency department can feel just as intense and overwhelming. Most of the time, you may be thinking you just want to win the race by getting home. When the nurse or doctor reviews the discharge paperwork with you before leaving the hospital, you may feel like you understand what was said, that is until you get home. That is when you learn, getting home is not the finish line; your journey has just begun as part of the transition of care team.
“Transitions of Care” is a term used by the Centers for Medicare and Medicaid Services (CMS) as a critical phase of time between leaving a hospital or rehabilitative (or Skilled Nursing) facility and returning home. Typically, discharge paperwork includes an “After Visit Summary” (AVS) with an explanation of the reason for your hospital stay (the diagnosis), and the medications prescribed, changed, or discontinued. The AVS also lists follow-up appointments scheduled with your doctors for bloodwork, X-rays, and home support services needed at home, such as visiting nurses. Misunderstandings and confusion during this period can lead to unwanted outcomes, including a return to the hospital.
The SoNE HEALTH Transition of Care program includes nurses who engage with patients to assist them with help understanding their condition, treatment plan, and the steps needed once home. Nurses are key liaisons, collaborating with physicians and other healthcare providers to ensure that patient care is coordinated and aligned with the patient’s overall health goals.
Nurses ask questions about how the person is adjusting to their return home and day-to-day activities, which can be stressful, especially when given new, or multiple, diagnoses. Lifestyle changes may include learning to integrate new medications, using new equipment,t or following new dietary recommendations.
By providing a safe space for the patient to ask questions, the Transition of Care nurse assesses whether the patient fully understands their plan of care goals and offers follow-up outreaches for ongoing care coordination. The team of nurse coordinators and doctors will continue to pass the baton of success,s enabling patients, as an integral part of the team, to remain on track with their recovery at home….and to cross that finish line.
- Larisa Baillargeon, LPN, Transitions of Care Coordinator
- Pam Bisaillon, LPN, Transitions of Care Coordinator
- Ivy Gregorio, MSHI, Population Health Administrative Assistant
