Why CareOne’s Transitional Care Program Is Right For You: Part 2, Managing Your Meds

During a patient’s healthcare experience, they are transferred from the hospital to a rehabilitation center before returning home.  They become accustomed to receiving around-the-clock medical care, including having their medications brought to them at specific times each day.  They don’t need to think about which medications to take when or the proper doses as everything is prepared by a nurse and brought directly to their bedside.  Once the patient returns home however, they are responsible for their medications.  They not only need to fill their prescriptions and have the ability to pick them up at the pharmacy, but they also have to understand which medications they are taking and why as well as when to take the medications and what doses to take.

Our Transitional Care Program makes the medication management process easy for patients.  Through our partnership with Walgreens, patients can have their medications delivered to them at their CareOne center prior to discharge.  This service eliminates the burden on patients and family members and puts patients in a better position upon discharge.  Our Care Navigators review all medication orders for accuracy and obtain clarification if any discrepancies are found.  They also provide information and education on each medication to the patient and their family members.

Once the patient is discharged and returns home, our Care Navigator schedules a home visit.  “One of the biggest benefits of the Transitional Care Program is the home visit,” says CareOne Care Navigator Sandra Palermo, RN.  “Patients are more comfortable in their own environment and it’s so much more meaningful because they can actually show me their medications and medical equipment and I can see what their challenges are and help the patient overcome them.”  A one-on-one home visit also enables our Care Navigators to ensure that the patient’s transition from their CareOne center to home is successful and that all of the patient’s needs are being met.

In addition to the home visit, our Care Navigators make weekly follow up phone calls to patients in the Transitional Care Program after they return home.  This increased level of communication provides us with the opportunity to discover any health issues that may arise so we can be sure to address them in a timely manner and prevent the patient from returning to the hospital.  “The Atlantic Accountable Care Organization Care Coordination Center works collaboratively with the Nurse Navigator at CareOne to help patients and caregivers transition back home,” says Atlantic Accountable Care Organization Complex Care Coordinator Catherine Thompson, MSN, ANP-BC, GNP-BC. “A dedicated transition nurse  is essential for improving communication among providers; improving medication compliance; supporting families; ensuring appropriate medical follow-up; and helping patients transition to a safe, appropriate care setting.”

Part 3 of this educational series will focus on the partnership between the hospital, CareOne centers, and the patient and the Personal Health Records our Care Navigators develop with patients to maximize communication between all partners.

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