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Health & Wellness > Health & Wellness 4 > HW 28

The Role of Telehealth in Transitions 

Recent studies have shown that 78% of patients leaving a hospital ER are confused about their diagnosis, treatment, and follow-up care and 20% of all inpatients experience an adverse event following discharge.

When individuals are discharged from the hospital or skilled nursing facility to return home, they often have little or no knowledge about the medications they have been prescribed, how to obtain their medications, and do not schedule a follow-up visit with their primary care doctor even when recommended by the hospital.  Research shows that without proper discharge planning and follow-up, many former patients find themselves readmitted to the hospital within 30 days.

And as a result of the recently-passed Patient Protection and Affordable Care Act, starting in October 2012, Medicare will penalize hospitals whose readmission rates within a 30-day period are higher than expected, therefore, hospitals will have even more financial incentive to help transition patients home and keep them there. 

‘Care transitions’ refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.” ~ Eric A. Coleman, MD, MPH

In his studies of care transitions, or handoffs, Dr. Coleman noted three factors that frequently cause problems.  First, the patient is not prepared for the self-care role. Second, medication reconciliation across the continuum of care is inadequate. And third, health care providers do not tell patients whom to contact with questions or concerns.

 Dr. Eric Coleman and The Care Transitions Program® have developed a strategy for improving care transitions and the intervention focuses on four conceptual areas, referred to as The Four Pillars®:

1.      Medication self-management: The goal is for the patient and his or her care-partnering team to be knowledgeable about and comfortable with the medications.  Including dose, time for administration, potential side effects to be aware of, and additionally, it is critical that there be a system in place for accurate administration of the medications.  Automated Medication Dispensers similar to those offered by Lifestyle Health Systems can be critical in ensuring patients adhere to a prescribed regimen.

2.      Dynamic patient centered records:  Everyone should understand and manage