Transitional care is a term that represents the time period of about 30 days post hospital discharge.
At HomeMD Housecall Services, our transitional care team consists exclusively of registered nurses who coordinate post hospitalization care so that our patients never slip through the healthcare cracks. Our automated software systems “talk” to the hospital’s software systems, such that we are automatically and seamlessly notified when our patients are admitted to hospitals, even when they are too sick, too preoccupied with their condition, or too distracted by their illness to let us know. Once our systems are flagged, our transitional care team gets to work, immediately engaging with hospital discharge planners so that post hospitalization care can be smooth and well coordinated. Upon discharge, our clinical team reaches out to the patient or their family to setup a post hospitalization visit, generally within 24-48 hours of our patient returning home. At HomeMD Housecall Services, we hold in high regard the nursing companies referred by the hospital to keep tabs on our patients and we understand that these companies and their nursing staff cannot treat our patients without our chart notes; we take a great deal of pride in knowing that at HomeMD Housecall Services we pull off what others can’t . . . whether it be onsite or telephonically driven, we see our patients quickly after discharge.
From there, our chronic care management team contacts our recently hospitalized patient every few days to make sure they are recovering well. We work hand in hand with all of the home health nursing companies to support their nurses by being available to answer their questions, validate their concern.
The period of time after a hospitalization is typically the most volatile period of time any patient or their family will experience . . . while we are trained to believe that “I’m all fixed” after a hospitalization, in reality, it is quite the opposite in most circumstances. Hospitals discharge much earlier than they did a decade ago and it is expected by the hospital system that home care nursing companies along w/ primary care teams will work with patients and their families to pickup the baton the hospital is handing them in such a way that they will defend against the risk of the patient falling right back into the inpatient setting. At HomeMD Housecall Services, we don’t just pick up the baton, we run with it!
We understand that after a hospital visit there are multiple people in and out of your home including nurses, physical therapists, social workers, and home health aids. Patients and their families must juggle these appointments, keep other family members updated, arrange for new medications to be picked up and/or delivered , and somehow keep a lookout for declines and new medication side effects that they may not be educated about pertaining to conditions that they are having to lookup on Google. At HomeMD, our registered nurse case managers from our chronic care management team will help you to coordinate all of those things so that our patients and their families can be made to feel that they do in fact have a lantern to guide them through what can otherwise be a confusing labyrinth of a dark cave.
Hospital discharge planners spend their entire day trying to control for what happens when a patient leaves the walls of their inpatient facility. All the phone calls, all the faxes, and all of the effort put into guarding a patient from the volatility of things the patient may not know how to control for can go “out the window” when a patient is unable to follow up quickly with a medical provider post discharge. The homecare company that the discharge planner has been coordinating with cannot evaluate or treat the patient in their home (ie. nursing, physical & occupational therapy, home health aid services, etc) without knowing that a medical provider has seen the patient and is willing to cover their orders for treatment . . . at that point, their patients are at very high risk of re-hospitalization.
For discharge planners all over Michigan, we invite you to experience the HomeMD difference! Our transitional care team will work closely with you during and after the inpatient stay so that you can finally trust the system again, knowing that your hard work will not go in vain. We will see our patient (or our new patient per your referral) within 48 hours of discharge and in most cases sooner upon your request. This visit may be onsite or telephonic, but it will get done and it will get done quickly. We will then coordinate closely with the homecare company of your choosing, or if it is one of our own patients for whom you are coordinating care for we will be happy to inform you who the homecare company it is that the patient is most familiar with. Allow us to take some of that work off your shoulders so that we may defend your outcomes with you!
Our staff strives to make each interaction with each patient clear, concise, and inviting and we do the same with the caregiver systems that support our patients, including you, the home care company. We will be there when you call us to give you the orders that you need, that is our commitment to you. No more phone tag, no more voicemails, no more waiting game. Each one of our providers has a dedicated office assistant who can provide you with your frequency orders and changes on behalf of the provider. We will be happy to do telephonic visits while you are with our mutual patients their homes and we commit that you will never, ever have to feel like you are chasing us down. Our field providers are all nurse practitioners so when coordinating care you will be speaking to an advanced practice nurse who has been in your shoes enough to know how very frustrating it can be to wait for clinic based providers to get back to you while making multiple phone calls to get your job done. You know what your patient needs . . . all you want is to be empowered with the tools to make your patient better and we want to be right there with you!