• Recovery Does Not End at Discharge
      June 6, 2013

      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.

      Plan for Discharge Before it Happens

      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.

      • Make sure you know as much as you can about yours or your loved one’s illness.
      • Know what medicines you will be taking and ask about how or if they might interact with medicine you were taking before you were hospitalized (or herbal medications or supplements you might have been taking). What are the possible side effects of the medication and how can those be managed?
      • If you are going home, ask if you will need to make accommodations in your home for your conditions – will you need a ramp for a wheelchair? Should you remove rugs or be careful around pets that may jump?
      • Make sure you have a clear plan for how you will get to your follow-up appointments if you cannot drive yourself. Ask about agencies in the community that might be able to help.
      • If you are going to a skilled nursing facility, utilize information about what to look for in choosing a facility.
      • If a family member is going to serve as a caregiver, does that person understand the demands of the position and feel prepared to undertake it?
      • Understand how your information will be conveyed to the next care setting.

      For a full checklist of items to consider before discharge, visit:

      Make Sure Expectations are Realistic

      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.

      Know the Pitfalls So You Can Avoid Them

      Below are some of the common areas where patients get into trouble after discharge.

      • Medication Errors (incorrect dosing, missing dosages or mixing medications that should not be mixed)
      • Establishing an Appropriate Caregiver
      • - Is a family member able to provide the right level of care or do you need home health services?
        - Is another inpatient setting needed as you move through lower levels of care?
      • How will care be paid for?
      • - Does your insurance and/ or Medicare cover the cost of your care?
      • Did You Ask the Right Questions?
      • - Some patients have concerns that they are not ready for discharge. This may be valid, or it may just be a manifestation of nervousness about what’s to come. If you have concerns, ask the hospital staff.

      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, home care 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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