Hospitals, Insurers Get Serious About Post-Discharge Care

There are some encouraging signs that the health care system is finally embracing the kinds of at-home care that can focus on the patients needs and keep them out of the hospital. Local insurance companies are working with a new provider, Landmark Health,(go to http://www.landmark health.org to read more about this innovative company)  that sends doctors to the home on a regular basis to make sure that at-risk patients who have recently been in the hospital get the follow-up care and monitoring they need. Doctors making house calls returns us to the kind of person-centered care that we remember in our younger days. These changes are being driven by health care policies that seek to cut  re-admissions to the hospital within thirty days of discharge.

Hospitals around the state and country are also starting to embrace community supports navigator programs.  In addition to in-home medical care provided by doctors and nurses, it is also clear that community services and social support are essential to successfully remaining at home. Community supports patient navigators are being used in some areas to successfully assist patients, their families and caregivers to navigate the complex medical and social services systems following hospital discharge.

The primary tasks for a navigator include support in the hospital while preparing for discharge, including completion of health care proxy forms and advanced directives. Once the patient returns home, tasks include arranging follow-up appointments and transportation, medication self-support. Support also includes health literacy by providing information to support patients with self-care and linking to health promotion, chronic disease self-management programs and support groups.

Referral to community services through the  local Office for the Aging NY Connects program and other services is also a role of the navigator.

Secondary tasks including grocery shopping assistance, reading mail, arranging for needed durable medical equipment, home companionship, caregiver support and planning for any emergencies.