This is the second part in our blog series exploring how we can work with the discharging hospital and our home health staff to be effective members of the care transition team. You can read Part 1 here.

Home care agencies and their facility partners must develop a more effective and shared responsibility for a patient’s transition to home. Agencies can assist with the initial transition of the care process, by ensuring certain things are accomplished prior to the patient’s discharge from the facility and admission to homecare. It is the duty of the management staff to no longer think about patients being discharged from the hospital but transitioned to home, which suggests equal responsibility.

Here are some tips to help to ensure a smooth transition of care.

(1)  Educate partners in the hospitals about the concept of care transition instead of discharge. The hospital and the homecare agency should work together, sharing responsibility for the care of the patient and proactively prevent readmissions.

(2)  Ensure the patient’s medications are ordered prior to leaving the hospital, and that the medications are covered by insurance and/or affordable for the patient.

(3)  Contact the patient’s primary care physician. Send information and setup follow-up appointment upon discharge, while identifying any barriers to getting to the appointment.

(4)  Request a discharge summary if the facility does not automatically provide them. This will give you all the pertinent information about the patient’s current health status and need for home care.

(5)   Identify the programs in place for your hospital referral sources. (Do they have transition nurses that go out to the home? Will a clinician monitor the patient’s outcomes?)  These efforts assist the home health admitting clinician in setting up services and frequencies.

(6)  Identify other ways to improve communication at time of patient transition of care and proactively identify any potential readmission risks.

The next entry in this series will focus on how best practices utilized by field clinicians may reduce hospital readmissions and impact patient care, not only for 30 days post-hospital, but also to prevent Acute Care Hospitalizations (ACH) for the entire certification period.