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Discharge Planning & Follow-Up Care Reduces Rehospitalization

One of the current and more frustrating problems facing a new ostomate today is the shortened hospital stays that are part of the cost control efforts of today’s “new” health care system.  The “get-them-in/get-them-out” procedure is barely enough time to come out of the anesthesia, wake up, and realize what’s been done, let alone get help, training and an understanding of an ostomy and its care. At Express Medical Supply, a medical supply store, we talk to many people who are discharged and they don't know how to properly wear their or how to fix issues with adhesion. This is very unfair to the patient and his or her family.  The medical establishment must find a better way.

Based upon the following, perhaps they have found the “better way”. A recent news release from the National Institute of Health, entitled “Transitional Care from Hospital to Home Improves the Health of Elderly Medical and Surgical Patients”, highlighted by a study of a more intense program of discharge planning and transitional care for the elderly.

Older people with common medical and surgical problems who were discharged from the hospital realized significant improvement in their health, at reduced costs to the health care system, according to research published in the February 17 issue of the “Journal of the American Medical Association”. The article tested a model of transitional care. It was led by Mary Naylor, Ph.D, RN, FASN, of the University of Pennsylvania’s School of Nursing, and supported by the National Institute of Nursing Research (NINR). Although this study focused on the elderly, it could, and should, be applied to everyone discharged from the hospital after any serious surgery.

The study used a multidisciplinary team and involved comprehensive discharge planning, including determination of patient care needs outside the hospital, and follow-up in the home by advanced practice nurses specializing in geriatrics. Findings revealed that six months after discharge, only 20% of the intervention group was re-hospitalized, compared to 37% for traditional discharges. Per patient days in the hospital were fewer for the intervention group– 1.53 vs. 4.0 for the traditional group, and the cost of post-discharge health services was about $600,000 lower.

According to Dr. Naylor, “The traditional care model is in sharp contrast with current practice, which leaves most patients, once discharged, on their own, to obtain necessary follow-up care.” (Anyone who has had recent surgery can attest to that.) In other NINR-supported studies, the model has been tested with highly favorable results in patient populations ranging from pregnant women with diabetes, to women undergoing hysterectomies.

Let’s hope that this study gets the attention of the health care professionals, and appropriate changes are made soon.

By: Bill Capman, Worcester MA New Diversions, Via: Hemet San Jacinto, CA
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