Why Choose Hospital to Home Care Transition Services

Returning home after a hospitalization can be stressful for your loved one. It also can also be stressful for you, the family member, if you live far away and cannot be there with them. You may worry about such things as:

  • whether your loved one can advocate on their own behalf
  • whether the health care providers will truly understand your family member’s needs, desires, and concerns upon discharge from the hospital
  • who will check on them once they get home to make sure they’re okay;
  • who will make sure that they get their medications
  • whether they understand what they’re supposed to do once they get home;
  • whether they’ll make their appointment and get to the doctor’s office for their follow up appointment
  • what will happen if they have complications related to their hospital stay.

A Shared Solution

Your Care Transition Advocate (CTA) , who is a registered nurse, will put you and your loved on at ease. Our hospital to home care transition services include:

  1. Pre-hospital Visit & Assessment. Our CTA will meet with your loved one and you prior or the hospital admission. If you cannot make it to the meeting due to distance, don’t worry – we can have you join us by videoconference or teleconference. This is the first step towards preparing for your loved one’s discharge. We will discuss the hospitalization and what to expect, assess your loved one’s current living environment and support system to determine services that will be needed upon discharge. We will also discuss any questions or concerns that you or your loved one may have about the hospitalization so that we can provide strong patient advocacy on their behalf once they’re in the hospital.
  2. Coordination with Hospital Team: We will meet with the hospital team who will be in charge of planning for your discharge (e.g. social worker, discharge planner). This begins soon after admission.
  3. Care Planning. We will ensure an easy transition from hospital to home by making sure that you and your loved one understand all discharge instructions. The care planning process includes:
    • Electronic Records. Many medical practices to include the VA, use electronic health records or a patient portal to store and track your medical progress, procedures, lab tests, appointments and medications. Most importantly, it allows you and your family member to be an active participant in your health care to include the decision-making process. It is also a way for you to contact the physician with any questions and concerns. We will ensure that your patient portal is set-up, you know how to access it; and information from your hospital stay is entered.
    • Medication Reconciliation. Patients often come into the hospital with a long list of medications and leave the hospital with more or different medications. Our CTA will review your family member’s current medications as well as any new medications that the doctor prescribes at discharge. The CTA will make sure that all medications are accounted for and that your family member understands the medications that have been prescribed and what they are for.
    • Education. Oftentimes, when you’re a patient in the hospital, it is hard to take everything in and truly comprehend the instructions provided by the hospital staff. Our CTA will make sure that you and your loved one understand your diagnosis, the treatment plan, discharge instructions and be your advocate with the hospital staff for any concerns you may have.
    • Follow-up Care and Care Management. Our CTA will visit your loved one at home upon return from the hospital. The CTA will also ensure that support systems are in place, that your loved one has his meds, ensures that follow-up appointments with the primary care physician has been made.   The CTA will then follow up with your family member by phone two times during the first week at home, then weekly for the next 4 weeks.

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