Seniors with major chronic illnesses who are discharged from hospitals don’t always recognize the critical nature of timely follow-up visits with primary care physicians, according to experts participating in IPRO’s 5-county Care Transitions program, which runs through July 2011.
Allison J. Wait, MS, RN, Clinical Educator and Personal Health Coach with The Eddy VNA in New York’s Upper Capital Region, visits patients during hospitalization to prepare them for outpatient self-care. She then makes home visits within 24 to 48 hours of discharge, at which time patients are coached on the need for timely office visits. Patients are scripted on what to say to obtain appointments and coached while making telephone calls.
“They don’t understand why they need to see a doctor when they were just in the hospital,” says Wait.
IPRO’s Care Transitions program is one of 14 taking place across the country. IPRO’s project targets five contiguous counties in the state’s Upper Capital Region-including Rensselaer, Saratoga, Schenectady, Warren and Washington counties. IPRO’s project is summarized in an article “Improving Outcomes Through Re-engineered Care Transitions: The New York Experience,” published in The Remington Report. For a reprint of the article, contact IPRO’s Communications Office at 516-326-7767, ext. 262.