Empower patients at the next level of care
Provide information orally and in writing
Every time an airplane takes off, airline staff empower passengers with information so they can be active participants in saving themselves if there is a problem, Nancy Skinner, RN-BC, CCM, points out.
"We need to do the same thing to empower patients and their families with information so they can be active participants in every transition of care," adds Skinner, a case manager for more than 20 years, principal consultant for Whitwell, TN-based Riverside Healthcare Consulting and a member of the National Transitions of Care Coalition.
Right now, the only safety net to ensure that patients are successful in the next level of care is to educate patients to understand their treatment plan, what's supposed to happen at the next facility, when it's supposed to happen, and who will make it happen, says Connie Commander, RN, CCM, ABDA, CPUR, president of Commander's Premier Consulting Corp.
"Everybody is waiting for the magic answer of how to transition patients between levels of care. In the meantime, we'd better start doing something," she says. "Consumers need to be educated that they can't be reactive in the health care mode. They've got to be proactive, and they can't be proactive unless somebody teaches them what they need to do."
Hospital case managers should ensure that patients have both written and verbal instructions, as well as providing the same information to the next level of care, suggests Jolynne "Jo" Carter, BSN, RN, CCM, director of network services for Paradigm Management Services LLC in Concord, CA.
For instance, if a patient goes home with home health care, give the patient the information about who is providing the care, what time to expect the home care visit, and who to call if no one shows up. Provide the information verbally and in written form.
"Things frequently fall through the cracks as patients move between levels of care. Patients are stressed when they're in the hospital and even more stressed when they're changing locations. They're not able to process information as well as they normally would. We need to reinforce the information we give them in a number of ways. They need to hear it, to read it, and to have somebody they can get in touch with when they have questions," Carter says.
In the acute care setting, patients get a lot of instructions at the time of discharge, she points out.
Take a marker and highlight the most important pieces of information in the discharge instructions so patients and family members can see it easily, she adds.
Assess whether the patient and family member are in a position to advocate for themselves. If not, take the next step to make sure the patient receives follow-up, Carter suggests.
This may mean notifying the physician office to check on the patient or ensuring that someone at the physician office will help coordinate the care.
"We need to do a better job of communication, well beyond the setting in which we practice. We need to make sure the patients understand what is going on so they can make sure they get the care they need," Commander says.
"We need to do the same thing to empower patients and their families with information so they can be active participants in every transition of care," adds Skinner, a case manager for more than 20 years, principal consultant for Whitwell, TN-based Riverside Healthcare Consulting and a member of the National Transitions of Care Coalition.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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