It’s Helen’s first day at the post-acute facility. As you may recall, she was discharged from the hospital to further recover from surgery. She and her family are extremely grateful the hospital medical team and discharge planners were able to use an automated discharge process tool to efficiently match her with just the right post-acute provider. The new organization has both the physical and occupational therapy services she requires, as well as the nutritional counseling she needs.
Well, even though they are a thing of the past, the post-acute provider has come up with many delicious alternatives that meet her dietary restrictions.
From the moment Helen arrived at the post-acute facility, she felt well taken care of. The organization had been in direct contact with the hospital to learn about her background as well as her physical, emotional and psychosocial needs. In fact, the hospital’s discharge planner used the automated discharge tool to electronically send key elements of Helen’s medical record to the post-acute organization. As a result, her caregivers at the new facility had all the information they needed to order her treatments and medications before she came onsite. So, on her first day, she received her medications on time and in full, met with her care providers and started her physical therapy.
A chief concern of Helen’s family is that she won’t progress in her therapy and will have to go back to the hospital—something that would not only be financially difficult for Helen and her family but also nerve wracking. However, the post-acute provider assures Helen that it’s in regular communication with the hospital to prevent a return visit. You see, the hospital identified Helen as a possible high-risk patient through its initial assessment process. As such, it’s closely monitoring her progress, making sure she is heading in the right direction and won’t need to come back to the acute setting.
Through the digital command center the hospital set up before Helen’s discharge, the post-acute provider and Helen’s family share information with the hospital about Helen’s condition. Everyone is watching to be sure there are no concerning changes that could warrant a return to the hospital. However, if something worrisome does emerge, hospital and post-acute providers will take immediate steps to prevent things from getting worse.
Over the next few days, Helen shows considerable improvement. The post-acute provider and hospital staff agree that she probably will be ready to go home soon. Stay tuned to hear about Helen’s next transition and how all her care providers will continue to work together to ensure she stays healthy over time.
For more information on creating a comprehensive plan for post-acute care, visit www.ensocare.com.