IRON MOUNTAIN - Dickinson Home Health recently launched its new Hospital to Home program, which seeks to ease the transition from hospital care to independent care for patients who need a little extra help to remain safe and healthy in their home environments.
The new program provides one free follow-up home visit to at-risk, non-homebound patients discharged from Dickinson Memorial Hospital in order to provide successful transition from hospital to home. A home health nurse will focus on medication reconciliation, home safety and community referrals as needed. The new program functions 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.
- Eligible patients will receive a visit prior to discharge from a nurse, discharge planner or social worker who will explain the program to them and their 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. "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. 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," added Tina Zarcone, RN, manager of Dickinson Home Health. "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, she explained. "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."