Why CareOne’s Transitional Care Program Is Right For You: Part 3, Keeping A Personal Health Record

Elder Care Services, NJ, Nurse Reading To Resident Photo - CareOne

The Transitional Care Program facilitates increased communication between each patient’s healthcare team.  While a patient generally sees a number of doctors, therapists, and social workers at the hospital, the rehabilitation center, and when they return home, our Care Navigators are with them from their stay at the hospital through their return home and constantly monitor their progress.

Our Care Navigators conduct an initial visit with the patient at the hospital and also meet with the patient’s healthcare team to get detailed information about the patient’s background and medical care and carefully review their medical records.  The Care Navigator is then able to pass this information on to both the rehabilitation center and home care staff, which ensures that critical information doesn’t get overlooked.  The Care Navigator follows up regularly with the hospital, the rehabilitation center, and the patient to confirm that all of the patient’s medical needs are being properly met and communicated to their entire team.  “CareOne was the first organization to partner with Robert Wood Johnson University Hospital New Brunswick’s Transitional Care Program,” says RWJUH New Brunswick Transitional Care Coordinator Teresa DePeralta, MSN, APN-BC.  “The true collaboration has helped the program spread its resources, continually improve the processes, while achieving positive reduction in unnecessary hospital readmissions. The CareOne team is always open to new ideas and come up with innovative solutions themselves.”

The Care Navigator works with the patient to create an up-to-date Personal Health Record (PHR) to coordinate the efforts of the patient’s entire healthcare team.  Patients keep track of their illnesses, medications, and any symptoms or side effects they may experience.  The PHR empowers the patient to take control of their health and enhances their healthcare experience by allowing for the sharing of accurate information.  “While I communicate with the hospital, rehabilitation center, and home care staff members, ultimately I work for the patient and help them navigate through the healthcare system,” says CareOne Nurse Care Navigator Silva Kubati, RN.  “Because I get to know the patients well, I can identify any changes in their behavior or health and communicate this critical information to their medical team.”

For more information about creating a Personal Health Record and our Transitional Care Program for you or your loved one, please call us at 1-877-99-Care1 (22731).