Post-acute care is a critical part of the healthcare continuum, providing necessary care for patients who require additional rehabilitation or support after an acute hospital stay.
Discharge planners play a vital role in helping patients transition from hospital to post-acute care settings. However, navigating the various options and resources for post-acute care can be complex and challenging.
To help discharge planners, there are several post-acute resources available that can aid in the selection and coordination of post-acute care for patients. These resources are designed to help streamline the discharge process and improve patient outcomes.
One such resource is the Centers for Medicare & Medicaid Services (CMS) website, which provides information on various post-acute care settings, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals. The website also includes tools and resources to help patients and families make informed decisions about post-acute care, such as a nursing home compare tool and a home health compare tool.
Another resource is the National Transitions of Care Coalition (NTOCC), a nonprofit organization that focuses on improving care transitions for patients. The NTOCC website provides tools and resources for healthcare providers and patients, including a transitions of care model, a medication reconciliation form, and a care transitions toolkit.
Additionally, some hospitals have their own post-acute care programs or partnerships with post-acute care providers. These programs can help to ensure continuity of care and improve patient outcomes. For example, Penn Medicine has a home infusion therapy program that provides high-quality, patient-centered care in the comfort of the patient’s home. The program offers comprehensive services, including medication management, infusion therapy, and nursing care.
In addition to these resources, there are several strategies that discharge planners can use to ensure successful post-acute care transitions for patients. These include:
Communication: Effective communication is essential for a smooth transition from hospital to post-acute care. Discharge planners should communicate regularly with patients, families, and post-acute care providers to ensure everyone is on the same page regarding the patient’s care plan and needs.
Care Coordination: Care coordination is critical in ensuring that patients receive the appropriate care and services during their post-acute care stay. Discharge planners should work closely with post-acute care providers to coordinate care and services, including medications, therapies, and follow-up appointments.
Patient and Family Engagement: Engaging patients and families in the care transition process can help to ensure that patients receive the appropriate care and support. Discharge planners should provide education and resources to patients and families, including information about post-acute care options, care expectations, and how to navigate the healthcare system.
Data and Analytics: Using data and analytics can help to improve the quality of post-acute care and patient outcomes. Discharge planners should collect and analyze data related to post-acute care, such as readmission rates and patient satisfaction scores, to identify areas for improvement and track progress over time.
