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Kendal at Oberlin Blog

Transitioning from One Type of Care to Another

Posted by Molly Kavanaugh on Oct 9, 2015 1:51:09 PM

Written By: Molly Kavanaugh

Many older adults and individuals with chronic illnesses routinely experience transitions of care, meaning they leave one care setting, such as a hospital or specialist’s office, and move to another, such as their home or another doctor’s office.  

These transitions present challenges for the patient and family, and can cause serious problems, according to the National Transitions of Care Coalition.

“Poor communication during transitions from one care setting to another can lead to confusion about the patient’s condition and appropriate care, duplicative tests, inconsistent patient monitoring, medication errors, delays in diagnosis and lack of follow through on referrals,” the coalition writes in its report entitled “Improving Transitions of Care.”

According to a study published in the Annals of Internal Medicine, one in five U.S. patients discharged to their home from the hospital experienced an adverse event within three weeks of discharge. Sixty percent were medication related and could have been avoided.


How to Advocate for your Health

Ask questions. Be prepared. Communicate concerns and desires. That’s how people should advocate for their health care, says Dr. Paul Haidet, who is involved with a Baylor College of Medicine program, “How to Talk to Your Doctor.”

If you or a trusted family member or a friend are unable to be an advocate, you might consider hiring a professional to help. The Alliance of Professional Health Advocates maintains a directory of its members, who typically charge a fee for services. The alliance also lists free and low-cost assistance provided by non-profit organizations.

At Kendal at Oberlin, residents with health concerns can request a “medical companion.” The companion is another resident who volunteers to accompany the person to a doctor’s appointment and open doors or assist with other issues. “Occasionally the companion comes into the exam room as a second set of ears,” says Don Norenberg, who heads up the sub-committee.  

The National Transitions Care Coalition offers several free tools and resources, including “My Medicine List” and a patient’s Bill of Rights during transitions of care.


The Future Outlook

Individuals with chronic conditions - a number expected to reach 125 million in the U.S. by 2020 - may see up to 16 physicians in one year, according to an article in the New England Journal of Medicine.

With the growing numbers, the need for improved transition of care is essential. A study by two University of Pennsylvania researchers found some promising innovations aimed at improving the quality of care for chronically ill older adults during critical transitions.

Colorado’s Longmont United Hospital developed an innovative patient program using volunteers and storytelling. Another hospital in Connecticut turned to a virtual discharge coach and a community-based organization.  


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Written By: Molly Kavanaugh

Topics: Retirement Community

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