You’re finally home and settled back in from a longer-than-expected visit to the hospital, followed by a short stay at a skilled nursing facility when you are readmitted to the hospital. Sigh. The uncertainty and disruption begin again.
A Patient Navigator’s Goal
Did you know your health is at highest risk during the time of transfers from the hospital to a skilled nursing facility or to your home? These are called transitions of care. ACN’s Care Coordination team works together to ensure you have the smoothest transitions of care possible.
When transitions are necessary, a Patient Navigator follows up within three days to ensure you understand your medications and have access to the resources you need. Patient Navigators are part of the Care Coordination team to protect your health by assisting with finding a provider for follow up appointments, identifying gaps in care, finding resources or resolving roadblocks. This helps you stay on the right track to full recovery.
Preventing Hospital Readmissions
One of ACN’s Patient Navigators, Sara, recently prevented a hospital readmission by following up with a patient who had just been released from a skilled nursing facility. As a result of diligently following up, Sara was able to identify a gap in care and get the patient necessary resources quickly.
“I first attempted to reach the patient two days after she was discharged from the skilled nursing facility. The patient didn’t answer, but I reached her a few days later,” Sara said.
Medicare recommends all patients see their primary care provider within three days of going home from the hospital or nursing home. When Sara finally got ahold of this patient, she had not seen a care provider for eight days.
“I called her and learned that the patient’s third-party home health company had not followed up or visited the patient. I reached out to the company and discovered they had closed this patient’s case in error, after receiving an incorrect notification that the patient had been readmitted to the hospital,” Sara said.
Sara was able to address the issue and arrange for a home health nurse to see the patient the following day. ACN’s Care Coordination team cares about helping you avoid the exhausting cycle of being in and out of the hospital. Without Sara’s expertise and persistence, this patient could have easily found herself right back in the hospital.
What You Need to Know
Our Care Coordination team is made up of healthcare insiders who are in your corner and want to help you maintain a healthy and independent lifestyle. Every step of your journey as a patient is important. That’s why our team collaborates to improve your overall health and prevent admissions and readmissions to hospitals or skilled nursing facilities.
Interested in learning more or seeing if you are eligible? Contact the ACN concierge at members@azcarenetwork.org.
