The transition period from hospital to home following a discharge is not only a crucial time to ensure overall patient health—it’s also an important opportunity for home health agencies and private duty care providers to band together.
With the health care system placing a premium on limiting hospital readmissions, coordinated care between private duty and home health providers can pack a double punch in keeping patients safe at home after a discharge.
A crucial time period
For Deborah Bradley, RN, MSN, clinical manager at Kankakee, Illinois-based Riverside Home Health Care, the care transition from hospital to home addresses the needs of the patients to ensure their recovery and overall safety at home.
“[Hospital to home] is an area where we can start to impact our patients and identify through thorough caregiver assessments what these patients need before they go home. This is where we need to partner with private duty agencies and impact patients right at discharge time,” said Bradley at the fourth annual Private Duty Symposium, presented by the Home Care Association of America, the Illinois Home Care & Hospice Council and LeadingAgeIllinois, on Wednesday.
However, a patient’s transition back into the home setting may not always be smooth sailing.
In fact, upon discharge, patients often feel like they are “kicked out” too soon from hospital care, according to Meredith Scafiezzo, MSW, social worker at Riverside Home Health Care.
Further, they are left with care instructions that they do not understand or are unable to perform on their own, she explained.
“The discharge planners in the hospitals are trying their best to discuss [care plans with patients] but, unfortunately, their main focus is length of stay,” Scafiezzo said. “[Discharge planners are] not always looking at patient-centered goals to keep these patients out and help them from [being readmitted].”
Fill in the gaps
This is where a partnership between a home health agency and private duty care providers proves crucial.
Scafiezzo explained that private duty care providers should really sell their services and highlight their capabilities to home health providers, and identify ways their caregivers can fill the gaps in between days when home health aides visit patients.
These gaps include providing assistance with bathing, helping a patient run errands and other non-medical services that can supplement the care being delivered by a home health aide.
When choosing a private duty provider to partner with, Bradley explained the importance of spending one-on-one time with the home health agency to iron out care coordination for a patient.
“I like that communication. I like the face-to-face,” said Bradley. “I work with one particular agency because I’ve gotten to know them. We’ve had a sit-down, we’ve gone to their office at times, but we’ll coordinate the care [and] how many hours their caregivers will be there, [and] have that conversation of what the care plan looks like.”
Overall, Bradley stressed the importance for private duty care providers to really communicate their agency’s capabilities to ensure a successful partnership with a home health agency.
“As a private duty agency, if you guys market to us … let us know your services, what you can provide, what your caregivers can and can’t do,” Bradley said. “We can take that information back to our discharge managers and social workers and really try to impact that time of discharge, and then it’ll make it easier for our transition of care.”
Written by Carlo Calma