How to More Smoothly Transition From the Hospital Back Home

Connected care helps navigate post-hospital care options
older man leaving hospital in wheelchair

You’ve just been discharged from a hospital after major surgery or treatment for a serious illness. Yet you need more help — maybe a lot more — before you’re ready to return home. A bewildering array of care options await you and your family.

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Suddenly you get the feeling that now you’re on your own. Why can’t the transition between hospital discharge and getting back home be smoother?

‘Dangerous time’ after hospital discharge

“The transition from hospital to the community is a dangerous time for patients. It’s overwhelming and scary,” says Eiran Gorodeski, MD, Director of Cleveland Clinic’s Center for Connected Care.

“Deciding what you need is so complex,” says Dr. Gorodeski. “From hospitals to skilled nursing facilities to rehabilitation to hospice care — it’s easy to get tripped up in all the choices.”  The Center for Connected Care works closely with patients, their families, and Cleveland Clinic’s inpatient Care Management staff to create safer transitions.

Another issue is “post-hospital syndrome,” a more recently recognized set of conditions where some patients encounter unanticipated new health problems as the result of the hospitalization itself. It puts vulnerable patients at risk for pain, confusion, increased risk of infection, arrhythmia, bleeding, and renal failure.

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How does connected care ease this transition?

Cleveland Clinic is part of a leading group of healthcare organizations around the country creating programs to ease the transition for acute care patients.

The overall idea is to strengthen the connection across the venues of hospital, home and nursing facility through:

  • Simplifying and clearing the healthcare path for the patient and family at the beginning of the process, to lead you to the various options you may need
  • Regular, consistent care from familiar physicians, nurses and other caregivers, including home visits
  • Maintaining current electronic medical records across all venues so doctors are up to date on the patient’s status

What’s under the ‘connected care umbrella’?

Cleveland Clinic’s Center for Connected Care gathers a range of post-hospital care under one umbrella. These include at-home care, skilled nursing facility services and palliative/hospice care.

1. “Home Care” encourages independence at home by providing specialty healthcare services, including home rehab, diabetes care, maternal/infant care, respiratory and infusion, as well as ongoing visits by physicians or advanced care nurses for geriatric patients with limited access.

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2. The “Skilled Nursing Facility (SNF) Connected Care” Program allows patients to receive ongoing care from Cleveland Clinic medical professionals five days a week at skilled nursing facilities. Doctors, nurses and other professionals are at these facilities full-time — not floating from one location to another so patients only see them once in a while.

3. “Hospice at Home” and “Palliative Medicine at Home” offers help and preparation for end-of-life care in the comfort of home. Families get guidance for making the treatment of advanced diseases as painless as possible, relieving and preventing further suffering before end of life. A hospice team makes routine visits and is available day and night for urgent visits and support —  preparing the patient and family physically, emotionally and spiritually.

Connecting all the dots

Different patients have different needs. Some require extra services. A system of connected care can accommodate these different needs and different situations. “There’s a whole menu of acute care direction,” says Dr. Gorodeski. “All of these services are just part of getting the links in the chain connected.”

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