Better Planning for Post-Acute Care at Home

After discharge from a hospital or other setting, many patients prefer to receive post-acute care at home as the familiar environment allows patients to exert some amount of control over their daily routine (including their sleeping and eating habits) and their follow-up care schedule.  These preferences are defined in the Picker-Commonwealth Program for Patient-Centered Care.  Patient-centered care is the practice of caring for patients (and their families) in ways that are meaningful and valuable to the individual patient – including listening to, informing and involving patients in their care.   

Dimensionalizing Patient-Centered Care
Harvard Medical School, on behalf of Picker Institute and The Commonwealth Fund, initially outlined seven dimensions of patient-centered care and an eight principle – access to care – was eventually added to the seven primary principles:

  • Respect for patients’ values, preferences and needs
  • Coordination, integration of care, and continuity
  • Information, communication, and education
  • Improved physical comfort
  • Emotional support; alleviating fear and anxiety
  • Involvement of family and friends
  • Continuity during and after transitions
  • Access to care

Planning for Post-Acute Care
The patient’s transition from hospital to home can be stressful, especially if the patient has experienced significant setbacks to one’s physical and mental well-being.    Home health agencies can proactively design and schedule a combination of at-home visits, virtual visits, and ongoing messages (including SMS, text, and/or email) to help engage patients on a continued basis by using a virtual care communication platform that prioritizes the patient’s individual preferences vs. family caregiver realities. 

Visiting nurses can initially meet (whether in-person or virtually) with the patient pre-discharge to help quell any anxieties a patient may feel in terms of “what happens next” when the patient returns home. The conversation continues – in-person and virtually – when the nurse reaches out to ensure that the patient is progressing as expected and that any immediate questions (especially related to medication, adherence, and/or emerging issues) are resolved in a timely manner.  Technology can also help resolve communication gaps as home health staff can use a virtual care communication platform to also integrate family caregivers into the patient’s virtual visits.  With the platform, the patient has the ability to also access care when needed, essentially making the care truly patient-centered.

A well-executed transition of care is essential to delivering the best patient-centered care. It should include a comprehensive care plan to ensure care coordination and continuity with the patient and their family at the critical turning points in care and during the change from the hospital (or another facility) to the home.  Ultimately, smart planning for post-acute care will influence better outcomes for the patients along with higher satisfaction for the patient and his/her family caregivers.

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