As the home health nurse, you recognize that Red Yoder is having difficulty managing his current illness, wound
care, and chronic conditions on his own and requires further intervention.
In situations similar to Red's, what are some strategies to improve care transitions from hospital to home?
Some strategies to improve care transition from hospital to home:
o Have the patient utilize the “teach-back” method when educating the patient or family.
This will ensure that the patient understands what is going on in their care.
o Promote the "Speak Up" initiative by the TJC
The brochure "Planning Your Follow-Up Care" lists patient-centered and safety-focused
questions that is to be asked by the patient prior to being discharged from the hospital.
o Encourage family involvement and direct them to the "Next Steps in Care”
o Complete a medication reconciliation list
Medications the patient was taking prior to admission
Medications prescribed during the hospitalization
Medications to be continued when being discharged
o Implement evidence-based interventions to reduce transition-related medication discrepancies.
o Encourage the patients to carry a medication list
o Keep a copy of recent medication reconciliation
o Share the medication lists with your healthcare team (primary care physician, specialty
physician, home health nurses, dietitians, social workers)
What are some barriers to successful transitions of care?
Barriers to effective care transitions have been identified at three levels.
1) The delivery system barriers
Each facility has reasons to prescribe or change medications according to their own medication formulary.
The constant change of medication can potentially create confusion for everyone involved in the care of the
patient (patient, caregiver, healthcare providers)
2) The clinician barriers
Nursing staff shortages force hospital to divert patients to other healthcare facilities, thus having a new set
of healthcare providers who probably won’t have the time to gain access through “care everywhere” on the
electronic health record.
3) The patient barriers
There is a lack of support from patients for improving transitional care until they or a family member are
confronted with the problem firsthand. Older patients and their caregivers often are not well prepared or
equipped to enhance the care they will receive in the next setting (LTC, home setting)
What resources does Medicare provide to promote care transitions?
According to medicare.gov, medicare will provide in-person office appointments within 2 weeks of returning home
from the hospital.
The health care provider who is managing the transition back into the community will work to coordinate
and manage your care for the first 30 days after returning home. They will work with you, your family,
caregivers, and other providers
The health care provider may also:
o Review information on the care you got in the facility
o Provide information to help you transition back to living at home
o Work with other care providers
o Help you with referrals or arrangements for follow-up care or community resources
o Help you with scheduling and managing your medications
This study source was downloaded by 100000879895845 from CourseHero.com on 02-25-2025 07:28:51 GMT -06:00
https://www.coursehero.com/file/144295259/Discharge-Planning-Discussiondocx/
care, and chronic conditions on his own and requires further intervention.
In situations similar to Red's, what are some strategies to improve care transitions from hospital to home?
Some strategies to improve care transition from hospital to home:
o Have the patient utilize the “teach-back” method when educating the patient or family.
This will ensure that the patient understands what is going on in their care.
o Promote the "Speak Up" initiative by the TJC
The brochure "Planning Your Follow-Up Care" lists patient-centered and safety-focused
questions that is to be asked by the patient prior to being discharged from the hospital.
o Encourage family involvement and direct them to the "Next Steps in Care”
o Complete a medication reconciliation list
Medications the patient was taking prior to admission
Medications prescribed during the hospitalization
Medications to be continued when being discharged
o Implement evidence-based interventions to reduce transition-related medication discrepancies.
o Encourage the patients to carry a medication list
o Keep a copy of recent medication reconciliation
o Share the medication lists with your healthcare team (primary care physician, specialty
physician, home health nurses, dietitians, social workers)
What are some barriers to successful transitions of care?
Barriers to effective care transitions have been identified at three levels.
1) The delivery system barriers
Each facility has reasons to prescribe or change medications according to their own medication formulary.
The constant change of medication can potentially create confusion for everyone involved in the care of the
patient (patient, caregiver, healthcare providers)
2) The clinician barriers
Nursing staff shortages force hospital to divert patients to other healthcare facilities, thus having a new set
of healthcare providers who probably won’t have the time to gain access through “care everywhere” on the
electronic health record.
3) The patient barriers
There is a lack of support from patients for improving transitional care until they or a family member are
confronted with the problem firsthand. Older patients and their caregivers often are not well prepared or
equipped to enhance the care they will receive in the next setting (LTC, home setting)
What resources does Medicare provide to promote care transitions?
According to medicare.gov, medicare will provide in-person office appointments within 2 weeks of returning home
from the hospital.
The health care provider who is managing the transition back into the community will work to coordinate
and manage your care for the first 30 days after returning home. They will work with you, your family,
caregivers, and other providers
The health care provider may also:
o Review information on the care you got in the facility
o Provide information to help you transition back to living at home
o Work with other care providers
o Help you with referrals or arrangements for follow-up care or community resources
o Help you with scheduling and managing your medications
This study source was downloaded by 100000879895845 from CourseHero.com on 02-25-2025 07:28:51 GMT -06:00
https://www.coursehero.com/file/144295259/Discharge-Planning-Discussiondocx/
