You can have an impact on ensuring safer transitions from one care setting to another by taking a few actions or using some of the key care transition tools listed below:
Most of us would rather stay at home and not go to the hospital at all. But when you need to go to the hospital, it’s important for patients and families to play an active role with the hospital staff to make sure that three important steps are completed before being discharged:
As part of the Stepping Stones Project, St. Joseph Hospital and its community partners in Bellingham, WA are testing the use of a plan with patients and families, designed to help both the patient and the hospital staff assure that these steps are completed before leaving the hospital.
A personal health record is a powerful tool that allows patients to organize, store, and keep track of health information. Health information that could be stored on a personal health record include: medications, immunizations, diagnoses, hospitalizations, surgeries, allergies, reactions to medications and health indicators such as blood pressure, cholesterol, and blood sugars. Sharing this information with providers is especially helpful during transitions from one care setting to another.
One of the primary goals of the Stepping Stones project is to encourage everyone to use a personal health record.
If you’re ready to take action, start using one today!
An exciting component of the Stepping Stones project is providing coaching to patients prior to, and shortly after being discharged from St. Joseph Hospital or a skilled nursing facility in Whatcom County. The primary role of the coach is to empower the patient and/or caregiver to take a more active role during healthcare transitions, and to develop lasting self-management skills. The coach supports patients over a four-week period that includes a facility visit, one home visit, and three follow-up phone calls.
If you are currently under the care of St. Joseph Hospital or a nursing facility located within Whatcom County, contact us to find out if you are eligible for coaching.
Effective management of one’s medications and having a list of all medications in one place and available to all caregivers and providers is important--especially during transitions of care. Medication self-management is one of the four pillars of the Care Transitions Intervention. Furthermore, medication reconciliation (the act of making sure that a patient’s medications are actively reviewed and adjusted throughout episodes of acute care) has been included as a Joint Commission National Patient Safety Goal since 2005. Studies show mismanagement of medications can lead to poor outcomes for patients and helping patients manage their medications can prevent the chance of harm.
You’ve started a personal health record and have learned about medication self-management. You are on your way to ensuring safer transitions for you or your loved one. There are many other resources available for patients and families such as tools for finding a good nursing home, Medicare beneficiary protection resources, tips for caregivers, and many more.
Learn more about your rights as a Medicare beneficiary.
