Care Coordination
Diabetes is a prevalent chronic condition among adults between the ages of fifty to eighty years. Diabetes can embroil the transition of care from hospital to home in diabetic patients. Readmission in hospitals contributes to rising medical expenditures, and thus it is a quality of care indicator. Lack of acknowledgment of the transition of care for diabetes patients contributes to increased visits in the emergency department and readmissions. If the healthcare systems adopt transitional care mechanisms, better health care will be achieved for patients by reducing hospital readmissions.
The transitions of care facilitated for my patient population include various interventions aimed at improving discharge to reduce readmission cases. These interventions include provider collaboration, patient education, and real-time after-hospital follow-ups. For instance, patient education involved interpreting the discharge summary for the patients so that they can follow instructions correctly. Since these patients are elderly, some of them could have dementia, which is likely to make them forget essential prescriptions, thus leading to readmission. Essentially, optimal health care for a patient is achieved by focusing on the disease and being concerned about the individual patient (Henry, 2018). Understanding the patient individually helps in understanding the factors influencing the prognosis of the disease. In other words, post-discharge interventions can improve the quality of care for diabetic patients through reduction of hospital readmissions by regular phone calls and home visits. According to Henry (2018), most diabetic patients who received transitional care had a lower readmission rate than those who never received the consideration.
Fortunately, there was a positive health outcome for the transitional case. The patient was given a discharge summary making it easier for her to understand her plan of care after discharge. The discharge summary was explained well to her and the caregiver to ensure all post-discharge instructions are followed keenly. Even though the patient never had her test results from the previous hospitalization, they were relayed from her primary facility to our facility. Since the patient did not understand how to use a glucometer, she was referred to a diabetic educator to show her how to use one. Also, the patient was advised to purchase her test strips out of pocket because her insurance could not cover the brand she was using. Similarly, the patient was advised to change her lifestyle and adopt a healthy lifestyle, which involves healthy eating, engaging in physical activities, weight management, and coping effectively. Also, the patient was advised on self-management of disease by managing and taking medications as required and regular monitoring of glucose. All these efforts were directed to cover the patient from possible future readmission with hyperglycemia.
Proper discharge protocols in a health care system can reduce issues associated with the transition of care. According to Henry (2018), they make the transition from hospital to home appear to be a seamless process that prevents readmissions, thus saving dollars that could be used in health care. For instance, within 24 hours of patient admission, the patient should visit the APRN to educate her educational needs. Also, the diabetic educator should be consulted to evaluate whether the patient knows how to use the glucometer besides providing more information about insulin. Also, the dietician should help the patient make appropriate dietary choices that will help her lose weight and manage blood sugar. Within two days of discharge, the registered nurse should follow up through phone on the patient’s progress.
