Talking to members about the transition home before and after a hospitalization is vital for service coordinators involved with the process.
Phina Smith-Hamilton, Director of Case Management at Henry Ford Hospital stated that service coordinators could be instrumental in providing referrals to additional care givers after a member is discharged. “It depends on what services are needed when it comes to community services, and the service coordinator being in touch with the patient after the hospitalization.”
Edie English, Director of Nursing at Beaumont Hospital in Taylor said patients have to disclose to discharge planners if he or she wants the service coordinator to be involved with the transition home.
English said that Beaumont currently uses home care agencies and The Senior Alliance to provide support to patients leaving the hospital. Sometimes, Adult Protective Services is used to make sure that the patient is safe in the home.
English suggested that home safety assessments could be one way that service coordinators could help. Currently, the hospital uses outside agencies, such as home care agencies, to conduct home safety assessments.
A priority for discharge planners, English said, is to “ensure a safe discharge in the safest location possible.” Additionally, care transitions involve making sure the patient is taking their medication correctly and a follow-up plan to keep the patients home.
The main priority for all professionals involved is to provide quality, person-centered care. “It really depends on the patient,” English said. “What does the patient expect out of the relationship? It’s about doing the right thing for the patient.”