IRON MOUNTAIN - A new "Hospital to Home" program will be launched by Dickinson County Healthcare System, providing one free follow-up home visit to at-risk patients discharged from Dickinson County Memorial Hospital.
Tina Zarcone, RN, Dickinson Home Health manager, outlined the program at the monthly meeting of DCHS Board of Trustees. The home visits are designed to provide a successful transition from hospital to home, Zarcone said.
A home health nurse will focus on medication reconciliation, home safety and community referrals as needed. The new program will function as follows:
- At the time of discharge from the hospital, the patient will be assessed to determine his or her eligibility for the follow-up home visits using a check list of specific criteria. (The criteria includes, but is not limited to, the patient's age, functional limitations, physical impairments, changes in medication, fall risks, etc.)
- Eligible patients will receive a visit prior to discharge from a nurse, discharge planner or social worker who will explain the program to the patient and family members.
- Upon patient acceptance, hospital staff will complete a referral sheet and contact Dickinson Home Health.
- Within 48 hours, staff from Dickinson Home Health will contact the patient to establish an
appointment for their home visit.
- The home health nurse will spend approximately one hour in the patient's home reviewing and reconciling patient medications, assessing the home environment for basic safety concerns, providing information for referrals to outside agencies that may be of benefit to the patient, and answering any concerns the patient may have once he or she has arrived home from the hospital.
- All information obtained during this home visit will be recorded on the Home Visit Record sheet to be included in the patient's medical record, and a copy of it will be sent to the patient's physician.
"Certainly patients have been fully assessed while they are still in the hospital to determine if they can be discharged home," explained Susan Hadley, RN, director of nursing at Dickinson Memorial.
"They are also given detailed instructions as part of their formal discharge. But that time of transition as they leave the hospital can be confusing to many, and both patients and family are not always ready to hear what they need to know in order to take care of themselves successfully once they get home," Hadley said. "So we are looking forward to working closely with home care nursing staff to complete and improve our discharge process."
Patients look forward to going home after a hospital stay, said Zarcone. "Once they are home, however, the full realization sets in that they are now responsible for their care, and many times family members are involved to help complete the cycle of care that the patient needs to fully recover. Questions arise that they may not have thought about while still in the hospital."
The visit provided through the Hospital to Home program has a very specific purpose, continued Zarcone.
"The nurse does not provide any kind of skilled care. This home visit is designed to help transition the patient more fully back home and to help guarantee he or she has all the information needed to remain safely at home through their recuperative process."
Among other things, the program should benefit DCHS by limiting the number of preventable hospital readmissions, Zarcone said.
The program also demonstrates the kind of services that DCHS can provide that are unavailable from out-of-area health care providers, said William Edberg, hospital board chairman.