A Collaborative Practice Model Initiative: Providing Pre-Hospitalization Preparation for Patients’ Safe Transition from Hospital to Home

Abstract

Rising health care costs and reduced health insurance benefits place enormous pressure upon today’s health care providers to deliver sound evidence-based care within restrictive timelines as the patient transitions along the continuum of care from hospital to community setting. The intensity of patient care needs in the current health care environment coupled with dwindling resources in the face of increasingly restrictive insurance coverage for patient care services threatens patient safety and impacts quality improvement initiatives. Efforts to prevent costly acute hospital readmissions while maintaining patients safely and effectively within their home environment with the requisite pharmaceutical, durable medical equipment and home care services support is challenging. A proactive case management system involving interprofessional health care providers has been developed in an acute care hospital that initiates discharge planning services within 30 days prior to patients’ admission for scheduled elective surgery or inpatient chemotherapy. The process includes identification of required post-hospitalization home care services and/or high cost specialty medications, prescriptions for which are received by nurse case managers who then initiate the process that secures smooth transition for patients as they return home. Preliminary evaluation of this process reveals increased readiness of the patient for discharge which translates into decreased lengths of stay and prevention of readmissions to the acute care setting. Using this Collaborative Practice Model to prepare patients for successful reentry to the community post-acute care hospitalization is highly relevant to interprofessional practice. Future studies should focus on quantifying objective measures to determine the success of the Collaborative Practice Model as it impacts on patient lengths of stay, discharge times on the date of discharge and readmission rates to the acute care setting. Learning Objectives: At the end of this session, participants will: 1. Discuss three restrictions on the availability of resources for patients returning home. 2. List three potential benefits of a pre-hospital discharge planning initiative on discharge time frames for the patient. 3. Identify three objectives measures that could quantify the success of a proactive case management program.