patient in a walker being transitioned home after a hospital stay

Hospital to Home Transition

The Hospital to Home Transition program is designed to promote a successful discharge and decrease the chance of readmission for the patient.

woman patient in walker being helped up the steps of her home after hospital stay

Many patients do not have a smooth transition from hospital to home.

The CHC Services team can work collaboratively with the discharging hospital to assure that a licensed Registered Nurse (RN) visits the patient in their home within 24-72 hours after discharge.

Ideally, a successful transition from hospital to home:

Ensures safety
Reduces the likelihood that the patient will have to return to the emergency room or be re-admitted due to a clinical complication
Reconnects the patient with his/her community physician and other healthcare providers
Gives the patients and his/her family a high degree of satisfaction and confidence that their clinical concerns have been appropriately addressed

CHCServices has developed a Home Transitions program that can address all of these concerns:

The CHCServices team can work collaboratively with the discharging hospital to assure that a licensed RN visits the patient in their home within 24-72 hours after discharge. The Nurse would provide a detailed assessment which would include:

A review of discharge information especially diagnosis and implications of this in the home and medication reconciliation
A comprehensive screening examination
A review of the components of the follow-up care plan
A review of potentially serious complications associated with medical conditions or prescribed treatments
An evaluation of the patient's support network
The completion of a brief satisfaction survey of the patient's hospital stay

Goal of Evaluation: Prevent ER visit, re-hospitalization, and increase overall satisfaction by patients and care givers.

The information obtained from this evaluation can be provided back to the treating team at the hospital or to the community physician and discussed with the patient and his or her caregivers. The spirit of this encounter is to put the patient in charge of their care by asking them or their care giver questions and there by encourage them to take a more active role in their care and well being.

Reimbursement for the service is usually received directly from the hospital, if the service is provided at the hospital's request, or from the patient, if requested by the patient or family.