Our Safe Transitions clinical framework focuses on one thing: getting our short-term rehabilitation patients home in a timely manner, functioning as safely and independently as possible. Our Safe Transitions program embraces the philosophy that discharge planning begins on admission and focuses on a patient-driven model which offers:
-Clinical programs that support the needs and goals of the patient
-Processes to define collaboration and timelines to meet length of stay expectations (defined by network partners/insurances and other health providers).
-Enhances coordination of services by promoting best practices and optimizing outcomes, fortifying partnerships with referral sources.
There are 5 components to Safe Transitions:
1. Discharge Readiness Checklist
Provides a structured means of identifying the specific areas each individual patient needs to address in order to achieve his/her specific goals.
2. Home Survey
Includes the therapist, patient and family member going to the home to assess performance in areas required in order to safely return to the home environment. This would include such things as entering/exiting the home, getting in/out of bed, in/out of a favorite chair and in/out of the bathroom and kitchen. Attention is given to detail in assessing for home modifications or equipment that may be needed to promote safe and independent functioning of the patient and the caregiver.
3. Cognition Assessment
A cognition assessment is completed when indicated to identify areas of need and implement treatment strategies to promote patient safety and independence.
4. Medication Management
Addresses the patient and/or caregivers ability to safely and independently manage their prescribed medications once they are in home environment.
5. Health Literacy Training
Health Literacy Training includes specific educational information to the patient and their family regarding the individual health needs of the patient, such as diabetes management, COPD management etc…to promote a good understanding of what is going on in their body and how they can proactively manage their health, thus decreasing the risk of future illness and possibly hospitalization.
HealthPro Heritage is our full service therapy partner and consultant on clinical initiatives. The Safe Transitions framework facilitates:
A multidisciplinary admission process to ensure immediate review and evaluation of patient conditions, needs and discharge plans.
Risk Assessment Process to identify risk factors for readmission or rehospitalization
Post-discharge communication to ensure safety, services and to mitigate transitions to skilled care facilities verses acute care.