Streamlining Transitions of Care

A dear friend of mine was hospitalized recently. She received excellent care while she was there. But when she went home, she and her husband felt very overwhelmed with managing all the new changes in her medications and setting up home health care services.

She made an appointment to see her primary care physician (PCP) and some specialists, who clarified what she needed to do and got her care back on track.

When a patient moves from a hospital to the home, or to another care facility, that’s called a transition of care. And unfortunately, it’s not unusual for people to have a hard time in these situations. Here’s a look at some of the communication breakdowns that can happen.

During a care transition, patients might not:

Understand how to manage their self-care instructions because of complexity, format, or language barriers.
Understand what medications they need or how to take them, or might not pick them up at the pharmacy.
Be aware of or able to schedule necessary follow-up tests.
Know who to call with questions or if their condition gets worse, or what symptoms to watch out for.
Have anyone at home who can help them recover or provide the things they need to get better.

Providers might not:

Set up needed home health services in a timely fashion (or at all).
Have follow-up appointments available for patients leaving the hospital, or may not help schedule them.
Have information about their patient’s treatment history, because the information was not transferred from the previous care setting.
Know patients’ preferences or therapeutic goals, because they haven’t been passed on from one care setting to the next.

One Solution: Seeing Your PCP Right After You’re Discharged

Smoother transitions of care mean fewer complications, less need for patients to return to the hospital, and better recoveries overall. To make sure you get the follow-up care you need, Independence Blue Cross (Independence) encourages you to connect with your PCP after being discharged from a hospital or other care setting — whether or not someone there told you to do it!

Research suggests that visiting your PCP after discharge makes you less likely to have to go to the emergency room or be readmitted to the hospital. And the sooner you see your PCP, the better — ideally within a month of being sent home.

If you’re an Independence member, our Registered Nurse Health Coaches will send you a letter after your discharge, reminding you to follow up with your PCP. These Health Coaches are also always available to support you during a care transition. To reach a Registered Nurse Health Coach 24/7, call 1-800-ASK-BLUE (1-800-275-2583; TTY/TDD: 711) and follow the prompt for Health Coach.

What Else You Can Do to Help Ensure a Good Care Transition

Here are more tips for making sure your care transitions are successful.

1. You may not be able to keep track of all the instructions your health care providers give you during and after your discharge from the hospital. You are, after all, SICK! And sick people need help from others.

So, don’t sweat it if you can’t single-handedly manage your own care transition. But you CAN choose a health care advocate who you deeply trust. This is a caregiver who can speak on your behalf, or take notes about what needs to happen when you are discharged. Bring them to your health appointments whenever you can.

If you’re an Independence member, you can use these forms to give people permission to interact with us:

Authorization for Disclosure of Health Information form — This form allows you to give permission for our Member Help Team to discuss plan and health information with your caregiver. Your caregiver cannot make any changes to your plan.
Personal Representative form — This form allows your caregiver to have full access to your member account and receive personal health information on your behalf. It also allows your caregiver to request a change to your information. Legal documentation must be submitted with this completed form.
Appointment of Representative form — This form is only needed when a caregiver is filing an appeal or grievance on your behalf, or speaking with a third-party vendor.

Learn more about how to file an appointment of representative form.

2. Keep a log of who you talk to about your care on the telephone (or have your health care advocate do it). Keep a little notebook handy so you can record the date; their name and role (nurse, social worker, case manager, doctor); who they work for; and their telephone number, as well as what they say to you.

3. Be aware that you will probably get some phone calls from either your providers or your health plan to assist you with your transition. (If you are an Independence member, you may get a call from one of our Registered Nurse Health Coaches.) Please let them help you!

Everyone in the health care ecosystem is trying to manage transitions of care better. If you ever experience a care transition, just remember there are things you can do to help it go smoothly.

Website last updated: 10/25/2022
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Independence Blue Cross offers Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal.
 
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company — independent licensees of the Blue Cross and Blue Shield Association.