A model care transitions program at Lee Memorial Health System in Florida shows how necessary it is to develop a patient-centered approach to care transitions that addresses housing and community services issues in order to prevent hospital re-admissions and improve the delivery of care. A review of the program’s success notes that prior to implementing the care transitions coaching, 60% of patients were discharged from the hospital system cited without any type of post-acute services. The care transitions project discovered “that some patients were not safe at home or quickly became depressed and lonely.”
They found “filthy nebulizers, lack of transportation to and from primary care physician visits, ineffective caregiving by a loved one, shut off electricity and even hunger.”
Also, “several patients did not know their diagnosis and had no idea what their diagnosis meant for their health. They had no understanding of whether their condition was acute or chronic and believed that the hospital had cured them.”
Using care transitions and coaching, they were able to reduce discrepancies in medical discharge orders from 92% to zero, re-admission rates have decreased and discharge planners have improved assessments to address the problems cited above including some of the community services which were lacking. A home visit is performed within 48 hours of discharge and psycho-social evaluations are done to identify needs before patients are sent home.
The program and results make it quite clear that there has been a great disconnect between the health care system and the patient’s understanding of their health care and their needs following a hospital discharge. It is clear that if re-admissions are to reduced, then health systems have to put in place extensive post-hospital care plans which educate and involve patients and caregivers and also make referrals to appropriate home and community based services. Patient navigators and coaches can plan a key role in making the care transition work.
