After grand rounds this morning at the University Medical Center at Princeton, the director of the recently created transitional care program, Kathleen H. Seneca, MSN, was speaking with one of our nephrologists about the purpose of the program. It fills the transitional gap for people discharged from the hospital that do not qualify (in terms of reimbursement guidelines) for home care, but would benefit from additional education, care planning, and hands-on instruction.
The director noted that, for example, these patients might learn something as simple as recording daily weight. They might learn what to do in the event of weight gain in a person with congestive heart failure or advanced kidney disease.
Another example is the time-tested “brown bag” visit, whereby the clinician, in this case an advanced practice nurse, reviews medications — when to take them, how to take them — potentially finding duplications, medications that were to be discontinued after discharge, or ones that were to be re-initiated after discharge.
It's about time! To paraphrase the nephrologist, “I can’t tell you how many times a patient is admitted three, four, five or six times a year for the same issue” that was not properly addressed in the transition from hospital to home.
The readers of Managed Care are likely saying, “Tell me something that I don’t already know.” My point: Take action! It really is just that simple.
Steven Peskin, MD, MBA, FACP
Executive Vice President and Chief Medical Officer
of MediMedia, USA, which publishes Managed Care