The Care Transitions Program is a low-cost hospital discharge planning and home follow-up program for elderly patients, designed to help them (and their caregivers) to play a more active, effective role in their own health care.
The Care Transitions Program is a low-cost hospital discharge planning and home follow-up program for elderly patients, designed to help them (and their caregivers) to play a more active, effective role in their own health care. It is provided by a registered or advanced-practice nurse, who acts as a “transition coach.” The transition coach first visits patients in the hospital to arrange a post-discharge home visit and to provide them with a personal health record. The record, which patients are instructed to share with future health care providers, includes a list of their health problems, medications, allergies, and warning signs/symptoms to closely monitor (“red flags”).
During the home visit, which takes place 48-72 hours after hospital discharge, the transition coach (i) reviews the patient’s prescribed medications to confirm there are no dangerous interactions, and discusses the medication regimen with the patient; (ii) uses role playing to teach the patient how to effectively communicate his or her needs to health care professionals; and (iii) reviews the “red flags” in the patient’s health record, including how to manage them and when to contact a doctor. The transition coach follows the home visit with three telephone calls during the first four weeks after the patient’s hospital discharge to insure the patient has received necessary medical services, medications, and equipment, and to discuss and answer any questions the patient has about recent medical appointments.
The program is inexpensive, costing approximately $140 per patient to implement in 2017 dollars.