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Care Transitions Program: Helping patients take charge of their health

“One of the ways Piedmont Hospital has taken a leadership roll in the community is to look at innovative programs that are available and how to partner with other provider agencies, particularly in the field of aging,” says Nancy Morrison, manager of Sixty Plus Older Adult Services at Piedmont Atlanta Hospital.

A recent example is Piedmont’s Care Transitions Program, which includes an onsite Care Transitions coach. “This is in partnership with the Atlanta Regional Commission Aging Division, which is our area agency on aging and this new, innovative program that is federally funded,” she says.

The Care Transition Coach

The program’s care transition coach is available to Medicare patients who need assistance transitioning safely back to their home after medical treatment. “One of the cornerstones of this program is how to effectively promote good communication between one healthcare partner and the next, and to educate the older adult about how to self-manage chronic conditions or other illnesses,” Morrison explains.

“Patients are identified by the case managers here at Piedmont. I visit them in their rooms and tell them about the program,” says Allison Davis, the Social Services Care Transitions coach. “Once they’re home, I set up a home visit.” Each home visit lasts approximately 45 minutes to an hour.

“I go over their discharge orders and make sure they understand them, and go over their medications to make sure they have everything that they need,” she explains. “We create a personal health record, which is a tool that they can use that contains all of their medical information. It also has a place where they can write questions for their doctors, so that when they get to their doctor’s appointment, they can remember what they wanted to ask.”

Davis helps her patients set monthly goals and reviews warning signs for when they need to see their physician. “Once I do the home visit, they understand the whole picture and are very good with the follow-up phone calls and tell me they’re keeping their doctor’s appointments,” she says.

“We get tremendous feedback from the families and the patients that have had this special service,” says Morrison. “It’s a win-win for everybody – the patients and the hospital.” “If they do readmit, I go and see them while they’re in the hospital and we discuss what went wrong and if anything could have been prevented,” says Davis.

The Family’s Role in Healthcare

Getting the patient’s family involved often yields better long-term results. “It’s great when you have the family involved as well because I can work with the family and coach them. A lot of times, families are the ones that identify things before the patient does,” says Davis. “If a patient isn’t feeling well, the family is more like to say, ‘This is what happened last time, so let’s go ahead and call the doctor.’”

Morrison encourages Piedmont patients to learn about and take advantage of the many programs the hospital offers, like Care Transitions. “If you happen to be a patient here at Piedmont, you might want to ask your nurse, the discharge planners or social workers that visits you in your room about not only what services are available to you through Sixty Plus, but any new programs like Care Transitions.” Click here for more information about the Care Transitions Program.

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