Part One of Helen's Post-Acute Journey
From the moment Helen was admitted to the hospital for surgery, her care team including her doctor, case manager, nurses, family members, and post-acute facility are working together behind the scenes to prepare for a smooth transition once it is time for her to leave. To support a successful recovery and reduce her chance of readmission after discharge, Helen’s care team employs a collaborative approach so she and her family know what to expect:
- Patient Dialogue: Helen and her family discuss the process at length with her care team – from the projected length of her stay at the hospital and post-acute facility, to her eventual at-home care plan and dietary restrictions. (Helen was disappointed to learn her nightly treat of chocolate-chip cookies were not allowed on the plan!)
- Discharge Preparation After her procedure, Helen’s physician and medical staff take advantage of their automated discharge process tool to identify the best post-acute facility to meet Helen’s clinical and non-clinical needs. With a referral-to-response time of less than 30 minutes, her care team quickly finds the right fit.
- Command Central: Another critical tool the hospital staff employs is a digital command center, which establishes care plan communication, ongoing monitoring (to make sure Helen sticks to that no-cookie rule), and a centralized way to make updates as Helen’s needs change. By establishing this prior to discharge, staff ensures a single source for clinical documentation from the very start.
- Communication Program: Now that Helen is preparing for discharge, the Healwrights need a step-by-step map of her care plan to follow going forward (detailing follow-up appointments, changes in medication dosing, etc.). They are set up with a secure online source to obtain this information, as well as the ability to contact the hospital’s medical team and access additional educational materials.
Though she doesn’t like the ban on her favorite chocolate-chip cookies, Helen is grateful for her attentive physician, dedicated care team, and supportive family during the discharge process.
Stay tuned as Helen moves on to post-acute recovery, the next step in her care management journey.
For more information on creating a comprehensive plan for post-acute care, visit www.ensocare.com.