Hand-off to Home Care Services

Research data has established a strong link between attention to care transitions and lower readmission rates. When and how a patient is prepared for hospital discharge greatly effects probability of success – which in this case is measured by not being re-admitted to the hospital within 30 days.

Everyone is aware of how hospital services have changed from the time of our parents. Much, or all, of the current patient admittance versus discharge is being driven by finances and insurance. There are no long stays at a hospital – it is too costly. Medical facilities need to move patients out to handle the volume of incoming patients, and to continue being paid by insurance.

Slowly, hospital discharge planning is incorporating home health care services as a solution to the re-admission problem. Instead of setting the patient “adrift”, knowledgeable administrators are constructing a “post-discharge” plan which utilizes the guidance and involvement of home care. When patients, especially the elderly, move from the hospital to the next site of care – be it to their home, or to a nursing home, or to a short-term rehabilitation facility, they benefit from having a clear treatment plan they can understand and follow. Home care providers who are aware of the transition plan (from hospital to home) can provide appropriate levels of care, management, and supervision as to the right medications and proper support services.