Topic: Care Transitions
What are care transitions?
-Acute to home or chronic care/step down
-Example: Hospital to home
Concern
-Don’t want patient to return to the hospital within 30 days for same problem
- Medicare refusal to pay for certain conditions to promote prevention
Issues
-Understand discharge orders
-Comply with discharge orders
-Drug coordination from pre-hospital, to in hospital, or post-hospital regimen
-Labs and services to follow up
Examples
-Pneumonia & Serious infections – injectable to oral antibiotic, antibiotics compliance, monitor for symptoms (temperature, swelling, pain, GI symptoms, dizzy/confused, etc.)
-Heart Failure – monitor weight everyday, comply with medicines
-COPD/Emphysema – arrange for O2, use FiO2 to expand vital capacity, correct use of inhalers
-Asthma – correct use of inhalers
-Heart Attack – BP, lipid, ACEI regimen of medications – promote compliance
-DVT – transition from injectable-to-oral anticoagulants – promote compliance, alert notification if bleed
-Pain management – CDC recommendations
Support
-Nurse case managers
-Pharmacists
-Home – rest, anabolic diet, hydration
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