Come Home & Stay Home with Trusted Transitions.
The Trusted Transitions program is a hospital discharge assistance service for King County seniors who are heading home after an inpatient stay. With 1 out of every 5 seniors being readmitted within 30 days of their initial discharge, the question to us was “how can we reduce the number of senior readmissions?”. After decades of research by scholars, doctors, and geriatric professionals, some prominent factors have been shown to consistently result in the rehospitalization of the elderly. By knowing the causes we were able to work towards developing a solution.
This program achieves the goal by having a Northwest Senior Care transition specialist ensuring that certain strategic steps are taken before, during, and after the transition back home. Some of the tasks that the transition specialist completes to ensure the lowest level of readmission risk are as follows.
Key Program Accomplishments
Verifying that all relevant contacts such as family members, primary doctors, pharmacists etc. have received both the hospitals discharge summary and Trusted Transitions summary.
Patient education assessment completed prior to discharge ensuring the seniors grasp on his or her condition, treatment, and expected outcome.
Contact made with the seniors pharmacist to discuss new and old medications, possible side effects, and warning signs to watch for.
Consultation with inpatient doctor or physical therapist regarding expected limits on seniors previous activity level and benchmarks goals.
Verification of schedule of follow-up appointments, including a mandatory phone appointment with inpatient doctor to assure progress and express concerns
Development of a “First 30 Days” calendar for the senior to reference regarding benchmarks, appointments, goals, etc.
These key program accomplishments represent only a portion of what is addressed by using the Trusted Transitions service. It hopefully highlights what can and should be done to help keep seniors safe at home after a stay in the hospital. For more information call us at (206) 910-8177 or send us a message on our Contact Page.
For more information on what you can do on your own to assist with the hospital discharge process check out the Care Transitions section of King County’s Aging and Disability Services page.