Why CareOne’s Transitional Care Program Is Right For You: Part 1, Patient And Family Education

Dealing with illness can be overwhelming for both the patient and their family.  From the number of physicians and health care professionals a patient sees, to the seemingly endless amount of information provided during the hospital stay, at the rehab facility, and then finally at home, it’s not uncommon for patients and family members to feel confused.  When a patient is unsure about an important element, like medication management, it can lead to rehospitalization.  The goal of the Affordable Care Act is to keep people healthy and reduce rehospitalization risks by providing a continuum of high quality care that includes increased communication between patients and healthcare providers.

According to a recent article in the New Jersey Star-Ledger, the results of a poll commissioned by the AARP found that 53% of NJ residents are or have been caretakers for sick or elderly relatives and wish they had someone showing them how to properly care for their loved ones after they had been discharged from the hospital.  In response, the AARP proposed The Caregiver Advise, Record and Enable (CARE) Act, new legislation that, if passed, will create a standardized method for all hospitals to prepare unpaid family caregivers for their post-discharge responsibilities.

CareOne’s Transitional Care Program, developed in accordance with the Affordable Care Act, is already providing the services outlined in The Caregiver Advise, Record and Enable (CARE) Act.  The goal of the program is to improve our patient’s outcomes, increase their confidence in managing their illnesses, and to maximize communication between the patient, their caregivers, and all of their healthcare providers.  We are the only rehabilitation centers that provide this vital service.

The program offers Care Navigator Services to both our patients and their families and provides them with a go-to person who can address all of their questions and needs.  Our Care Navigators are registered nurses dedicated to guiding and educating patients and their loved ones through the patient’s entire healthcare experience, beginning at the hospital.  Care Navigators continue to follow the patient throughout their rehabilitation stay at CareOne, and even after the transition from CareOne to home to ensure that the patient remains in good health.  The Transitional Care Program focuses on three main areas:

  1. Patient and Family Education
  2. Medication Reconciliation
  3. Keeping a Personal Health Record (PHR)

This three-part educational series will explore these principles to help you better understand how our Care Navigators can ease the process for you and your loved one and relieve some of the stress associated with illness. According to Serena Juliano RN, BSN, CareOne’s Director of Care Navigation, the main reasons a patient returns to the hospital are:

  • Medication-related complications – the patient doesn’t take their medication, they take the wrong medications, or they don’t fill their prescriptions.
  • The patient doesn’t follow up with their doctor within a week of returning home.
  • The patient does not understand the signs and symptoms of their condition(s) so they don’t realize when they need to seek medical attention.

Through patient and family education, our Care Navigators empower patients and their families in self-management of their chronic diseases and provide vital information on medication management, the importance of making follow up medical appointments (and even make appointments for the patient before they return home), and recognizing the “red flags” of the patient’s condition.  “Having a go-to person is important for patients and families.  It eases the process for them and helps them transition successfully through the different stages of healthcare,” said Juliano.  “I help patients understand what they can do to keep themselves healthy and work with them to identify their health goals.  Once they are able to identify their goals and the steps they need to take to achieve them, they are motivated to succeed.”  By educating patients, CareOne empowers them to take control of their health so they can eliminate the risks of further complications and remain in their home environment.

Stay tuned for Part 2 of our educational series, exploring medication reconciliation and the ways in which our Care Navigators ensure that patients understand all aspects related to their medications.

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