Right Transitions assists patients returning home

For patients who are discharged from a hospital or care facility, having a trained caregiver at home can mean the difference between staying at home and being readmitted. A mix-up in medications, little food in the fridge and lagging energy to bathe and dress are among common post-discharge challenges for patients. Lack of transitional care or care provided in the home by untrained caregivers can lead to medical complications, readmission to the hospital and even death.

Roughly one in six Medicare patients who leave a U.S. hospital will be readmitted within 30 days. Hospitals and other health care facilities risk heavy penalties from Medicare if they have a high percentage of avoidable readmissions too soon after discharge. The Center for Health Information and Analysis estimates that the annual Medicare cost of hospital readmissions is $26 billion, and $17 billion is considered avoidable.

While many individuals do remarkably well transitioning home after a surgery, illness, injury or other medical condition, elderly people often struggle to navigate the activities of daily living. Katherine Watts, LMSW, ACM-SW, director of Medical Social Services at Lexington Medical Center in West Columbia, S.C., finds that “one of the greatest challenges with care transition is helping patients understand their discharge plan, then helping them transition back into the home safely where they feel comfortable taking ownership of their care.”

“Our Right at Home caregivers make it possible for thousands of post-discharge patients nationwide to make safe transitions from hospital to home,” said Valerie Cadenhead, owner of Right at Home Central Arkansas. “We help ensure that our clients receive an additional level of support once they leave a hospital or other care facility, and we help them successfully transition to their own home and stay there.”

When a patient moves from one facility to another, including a transfer home, it can be difficult to coordinate information about the patient’s treatment. But the RightTransitions program can help ensure all stakeholders are kept up to date on the patient’s care — the goal being to keep the patient at home and out of the hospital. The services of the RightTransitions customizable care model can include:

• Conducting frequent follow-ups with families and discharge planners.

• Helping the patient comply with the care plan prescribed by the health care providers.

• Coordinating communication between providers.

• Watching for red flags — reporting concerns to the clinician.

• Providing transportation to/ from medical appointments.

• Supporting patient self-management.

• Preparing nutritious meals.

• Running errands.

• Managing everyday health reminders.

• Keeping the home clean and safe.

“Having a caregiver in the home planning and preparing meals and directly interacting with the care client really makes a difference in maintaining an appetite and eating nutritious foods that promote healing and regaining of strength,” Cadenhead notes.

For more information about RightTransitions in your area, contact Right at Home at 501-321-4962 or visit http://www.rah.car.com/.