How can a good care transition team make a difference for hospitalized patients?
While a hospital stay can be a stressful event, leaving the hospital can also feel overwhelming. The transition to home can be particularly challenging as patients and their families take over the responsibility of care coordination. Plus, there’s likely new information and medications to navigate, as well as follow-up appointments with doctors and specialists that require scheduling.
Every year, the cost of hospital readmission in the US reaches the billions. When patients are readmitted to the hospital numerous times, it puts undue stress on them and their loved ones. This repetitive cycle can be physically and emotionally draining, which can exacerbate or even lead to further illness.
Going Above and Beyond the Hospital Stay
At Holland Hospital, our Care Transition, Telehealth and Transitional Heart Failure Program (THFP) teams offer comprehensive support that goes above and beyond the hospital stay. *Together, these teams help patients with chronic diseases or specific health diagnoses take control of their health and wellness after discharge, lowering their risk for re-hospitalization.
Post-acute care nurses work to enhance each patient’s self-management skills, as well as coordinate with their primary care and specialist physicians. “When people think of patient care, they probably only think about what happens during the hospital stay,” said Ronnie Richards, RN, manager, Holland Hospital Post Acute Care Programs, “but the transition period from hospitalization to home or another facility is critical.”
“Because they aren’t scripted calls, the phone calls made by our nurses are more meaningful. They really check in with what’s going on in each patient’s life,” she added. “It’s prescriptive, but also individualized to the patient’s needs.”
In addition to regular phone contact, Holland Hospital offers care transition patients 30 days of free telemonitoring that includes blood pressure, pulse oximetry, weight and blood glucose (sugar) checks. Data collected can help identify any immediate concerns and assist providers in making earlier treatment interventions. To ensure patients feel comfortable and confident using telehealth equipment in their home, our telehealth assistants also provide troubleshooting expertise and work in harmony with our nurses.
Taking Heart Failure Readmissions to Heart
Added in 2020 to complement our Care Transition Team, the THFP is delivered in partnership with Spectrum Health Cardiovascular Services. This specialized team provides ongoing education and care specific to heart failure patients, a population at high risk for re-hospitalization.
Heart failure patients are given a special toolkit, including a measuring tape, organic seasoning and a low-salt cookbook written by the American Heart Association, to help them better manage their disease and stay out of the hospital. Compared to the national average of 21.9%, Holland Hospital’s 30-day rate of readmission for heart failure patients enrolled in the THFP is 10.38%.
Holland Hospital has served the West Michigan lakeshore region for over a century, earning national recognition for delivering top quality care, exceptional patient experiences and superior value. Learn more about Holland Hospital Home Health Services.
*Delivery of care transition services depends on disease diagnosis and insurance coverage. Not all patients qualify.