Peninsula Home Care Partners with Area Hospitals to Provide Continuous Care to Patients during Hospital-Home TransitionPublished on - August 24, 2016
SALISBURY, MD – When a loved one is admitted to the hospital for congestive heart failure, it’s not something a family takes lightly. They want to make sure their mother, father, sister, or grandfather receives the best medical attention available. But when the individual is discharged from the hospital, a feeling of panic may set in because family members don’t always know what they should do to continue giving their loved one the quality care they need to recover.
To ease that sense of helplessness and anxiety, Peninsula Home Care is working collectively with Peninsula Regional Medical Center (and other area hospitals) to provide the best quality care to patients from the moment they are admitted to the hospital to the time they are discharged and head back home to continue their recovery.
“When a patient is discharged from the hospital, they transition from being constantly monitored by health care professionals to being on their own or cared for by family or friends,” said Jennifer Kline, Peninsula Home Care Maryland branch director. “And while care givers are concerned about the patient’s well-being, they may not have the necessary skills required to care for their loved one’s health needs.”
“We have a transition of care team that provides care for a patient for 30 days after discharge,” said Kathryn Fiddler, Executive Director Population Health, Peninsula Regional Medical Center. “Our nurses coordinate directly with Peninsula Home Care nurses to talk about a plan of care, follow up with the individual’s primary care physician and educate the patient and family about the condition or illness.
This open communication allows us to continue to foster relationships with our partners as we are building streamline continuum of care passageways for our patients.”
For the last eleven years, Sue McPhail, Peninsula Home Care RN and case manager, has been the liaison between PRMC, PHC and the patient.
“When people are sick they don’t always hear what they are being told in the hospital,” said McPhail. “That’s why we are here. We help make the transition from hospital to home as smooth as possible. This requires the patient to understand their plan of care upon discharge and have the support, resources and education they need to not only prevent readmission to the hospital but continue their recovery at home and eventually gain their independence to get back to their lives.”
Long Distance Health Care for High Risk Patients
Patients diagnosed with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are known to have the highest hospital readmission rate. When not managed properly, they are among a handful of chronic illnesses that can lead individuals back to the revolving door of the hospital with little time in between visits.
Peninsula Home Care’s telehealth system lowers a patient’s readmission risk. The free service provides patients with high-tech medical monitors that track health conditions and alert home care nurses of any issues, recurrences or flare ups.
“Patients at risk for repeat hospital admissions due to chronic conditions often require close home monitoring to prevent any exacerbation of their condition,” said Kline. “These monitors do not replace the home visits our nurses and therapists make. They are an additional tool to prevent readmissions to the hospital, keeping people in the comfort of their home during recovery.”
The monitors provided to patients track and record critical health information such as blood pressure levels, pulse-rate, weight and blood oxygen saturation levels. For a CHF patient, a change in weight could signal a red flag to the nurse and support can be provided sooner than later which could save the patient a trip back to the ER.
Facts about CHF
Congestive Heart Failure is the leading cause of hospitalization in people older than 65. It is a chronic condition in which the heart doesn’t pump blood as well as it should. As a result, the heart cannot pump enough oxygen and nutrients to meet the body’s needs.
To keep heart failure from worsening, a patient must make major changes in his life. They may need to eat differently, remember to take medication and keep as active as possible. Here are some other tips to follow when managing CHF.
- Keep blood pressure low
- Monitor your symptoms
- Maintain fluid balance
- Limit how much salt (sodium) you eat
- Monitor your weight
- Take your medication as prescribed
- Schedule regular doctor appointments
About Peninsula Home Care at Nanticoke
Providing care for more than 30 years to more than 39,000 patients on Delmarva, Peninsula Home Care at Nanticoke in Seaford, Delaware ensures that all patients are involved in their plan of care and strives to give them every opportunity to maintain their independence in the home. In 2016, Peninsula Home Care at Nanticoke achieved the highest star rating (5 out of 5) in patient satisfaction survey results. For more information, visit www.peninsulahomecare.com.