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Transitioning Home from a Facility

Going Home with an Interim NurseUpon being discharged from a hospital or other medical facility such as a nursing home or rehabilitation facility, many individuals and their families believe that the toughest part of their recovery is behind them. However, in reality, it usually means the beginning of a whole new routine at home – one that involves more organization, effort, and awareness. How prepared a person is for returning home can make the difference in being at risk for hospital readmission. This is why many families choose Home Care Services from Interim HealthCare.

Most of the people who face the greatest risk of returning to the hospital are people with more than one chronic disease. This is a large number of individuals as one in four people over the age of 65 have a chronic disease. The most challenging of these chronic diseases are Heart Failure (HF), diabetes, Chronic Obstructive Pulmonary Disease (COPD) or Coronary Artery Disease (CAD) or any combination of these which is not uncommon with advancing age.

Interim Transitions℠ offers a variety of services to help hospitals, skilled nursing facilities, and inpatient rehabilitation teams reduce avoidable readmissions when skilled home health care is ordered, as well as when a patient is not eligible for a home health benefit but the facility discharge or transitions team has concerns about the patient managing when they return home.  The services offered by Interim HealthCare franchise offices can include the “Living with HF, Diabetes, CAD, or COPD” programs, as well as private pay chronic care support offering personal care and/or nursing focused on the key behaviors that can reduce readmissions.

InterimTransitions℠ services can ensure that the patient, as well as family:

  • Knows what to expect when discharged or “transitioned” to their home – this can be significantly enhanced by an inpatient visit before discharge by the Transitional Care Coordinator or private duty supervisor to help the patient and family understand the home care services available.
  • Knows what prescriptions the patient will be discharged with and which among those at home are continued, dosage changed or should be discarded- this should occur within 24 hrs of arriving home and involve an RN home visit which can include contact with the patient’s community physician and/or pharmacist; this visit is the first visit under a home health benefit  or as a private pay RN visit following discharge for the purpose of medication reconciliation.
  • Understands which medications should be taken, when and how much, as well as have a system in place that works for the patient to ensure that they take their medications when the health care team is not present. This is a goal of skilled home health care or a private pay medication set-up service.
  • Knows the signs and symptoms to monitor that mean that their condition is getting worse. Know who to call and when with the goal of staying out of the ER and the hospital. This is part of patient care plan of skilled home health and can also be continued by private pay personal care aides when there is no longer a need for skilled care.
  • Gets the patient to their physician within 14 days of discharge from the facility.

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