When you or a loved one is discharged from an acute care hospital, or from a long-term acute care (LTAC) hospital such as one of Kindred’s transitional care hospitals (licensed as acute care hospitals and certified as LTAC hospitals) recovery does not end. In many ways, it begins – whether you are going to another care setting or home.
Many studies have shown that the period after hospital discharge, or the transition between acute care and a lower level of care, represents one of the times in healthcare when the patient is most vulnerable.1
“Family conferences with our interdisciplinary team of care providers help our patients and families become oriented to the continuum of care needs that they have, and their progress along that continuum,” said Sandra Morgan, Chief Clinical Officer at Kindred Hospital Bay Area in Tampa Bay, Fla. “It is very important to them to have our experts give them advice on next steps and planning.”
There are several important ways you can take an active role in making sure yours or a loved one’s discharge is not an end but a step toward further recovery and meeting your personal objectives at the next level of care.
Like Kindred Hospital Bay Area in Tampa Bay, many facilities offer discharge planning resources or a dedicated staff member to aid patients with discharge plans. Take advantage of these resources. Ask the right questions and voice your concerns.
For a full checklist of items to consider before discharge, visit: http://www.caregiver.org/caregiver
It’s common for patients or their family members to expect to return to their pre-hospital self after a health event. This is often simply not realistic, and not realizing this can lead to disappointment and depression. At the very least, many patients will need to make lifestyle changes to prevent the kind of event that precipitated the hospitalization from happening again. These may include dietary or exercise modifications. At the other end of the spectrum, many patients require extensive further treatment, monitoring or rehabilitation. Before leaving the hospital, make sure you understand whether or how much the patient’s condition is expected to improve, and what further therapy or treatment is needed to ensure the best outcome.
Below are some of the common areas where patients get into trouble after discharge.
Better coordination across sites of care is expected with the passage of the Affordable Care Act, which penalizes acute care hospitals with higher-than-expected readmissions rates. As a result, acute care hospitals and post-acute care settings, including long-term acute care hospitals like Kindred Hospitals, and skilled nursing facilities, inpatient rehabilitation hospitals, homecare and hospice providers are working together better than ever to ensure that discharge from one setting is not an end, but a step toward reaching a patient’s recovery potential. Patients and their loved ones can be important participants in this team process toward excellent outcomes.
“Connecting the dots throughout a patient’s episode of care leads the way to safe, efficient treatment from their admission at a long-term acute care hospital through their discharge home,” said Derek Murzyn, Chief Executive Officer of Kindred Hospital Greensboro in Greensboro, NC. “Treating appropriate patients at the appropriate level of care at the appropriate time is the best way for us to leverage clinical resources and physician expertise to offer patient-centered, comprehensive care.”
Vivian had a tumor on her trachea that needed removed. This is the her story of recovery and how she moved through Kindred's Continuum of Care, receiving the most appropriate care for her at the right time so she could recover quickly and get home to her family. Click play below to watch this short video.
1Okoniewska BM, Santana MJ, Holroyd-Leduc J, Flemons W, O'Beirne M, White D, Clement F, Forster A, Ghali WA. “The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool.” BMC Health Serv Res. 2012 Nov 21;12:414.
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