Transitions of Care: Helping Our Members Navigate Hospital Stays

Hospital Nurse With Digital Tablet Talks To Senior Patient

When you’re admitted to the hospital for an inpatient surgery or procedure, there’s a lot to manage. Depending on the reason for your hospital stay, there may be pre-admission paperwork, discharge instructions, medication management, follow-up appointments, side effects, physical therapy, home care services, and financial considerations.

Our Transitions of Care Program

That’s where the Independence Blue Cross transitions of care program can support you. Our registered nurses will reach out and provide coordination of services and resources to members who may need additional support to ensure a smooth recovery. From pre-admission to inpatient to post-discharge, our Case Management team supports members moving from one health care setting to another.

For example, if you recently had heart surgery and you are leaving the hospital to head home, our registered nurse Health Coaches are there to help you every step of the way, from pre-surgery prep (pre-admission) to your time in the hospital (inpatient) to your recovery at home (post-discharge). Since it is a fluid process, you may be identified for outreach at any point during your health care journey (pre-admission through post-discharge). Once you start working with a Health Coach, you continue to work with that same Health Coach until you’re feeling better. There is no cost to you for this service and all information is kept confidential.

Preparing for your hospital stay

For select inpatient procedures, a registered nurse Health Coach will contact you to discuss your upcoming admission plan and support you during your hospital stay as well as after you are released.

Health Coaches offer one-on-one personalized support by assessing your health status, identifying potential issues, and establishing plans to address any roadblocks to recovery. Your Health Coach will assist with care coordination and may reach out to additional health care resources, such as our licensed social workers, pharmacists, or our behavioral health specialists.

Health Coaches can help you achieve a successful recovery by assisting you with planning ahead for the admission and discharge. They help by:

  • Determining your understanding of the reason for the admission
  • Checking your knowledge about the procedure scheduled during admission, and offering education and information as needed
  • Assessing your expectations during hospitalization, recovery, and post-discharge
  • Addressing any concerns about your upcoming hospitalization

They will also discuss the potential plans for follow-up after you leave the hospital:

  • Are you aware of the signs and symptoms that would be indicators for you to call your primary care physician (PCP) or return to the ER? (If not, your Health Coach will review these signs and symptoms.)
  • Do you have discharge instructions? (Your Health Coach will review any discharge instructions with you to ensure you understand them.)
  • Did you make a follow-up appointment with your PCP or specialist within 7 days of your discharge? If not, your Health Coach can assist you with scheduling.
  • How will you get to your doctor’s appointments? If transportation is needed, your Health Coach can refer you to a social worker.
  • What medication(s) are you on? Do you understand what each medication is for? Can you get the medication from the pharmacy? Can you afford the medication? If you are on several medications, your Health Coach may consult with a plan pharmacist.

Depending on your situation, your Health Coach may also refer you to a social worker for additional community resources. For example, your Health Coach may contact a social worker if you cannot afford your copays for medications, or you need a referral for transportation resources.

During your hospital stay

Based on select diagnoses or procedures, your Health Coach may contact you during an inpatient hospital stay to introduce case management, assist with your discharge plan, and follow you through your first follow-up appointment. If you need continued support, your Health Coach will support you until you are able to manage on your own.

After you leave the hospital

After you are discharged from the hospital, your Health Coach may work with you to:

  • Address any immediate concerns or questions
  • Discuss your discharge instructions to make sure you understand your plan of care
  • Review medications, including any new medications or changes to existing medication, potential side effects, and when to notify a doctor if adverse reactions occur
  • Review early signs and symptoms to report to your doctor (as they may indicate a worsening health condition)
  • Remind you of the importance of post-discharge follow-up appointments, e.g., PCP/specialist appointments and/or therapies/treatments/equipment ordered

Working Together for More Coordinated Care

Your Health Coach will also work with your doctor to make sure you receive coordinated care. Your Health Coach will make suggestions about what to discuss with your doctor, including:

  • Your discharge summary
  • Discharge medications and current medications (including over-the-counter medications, herbs, supplements)
  • Directions for taking medications as instructed (on an empty stomach, with food, at bedtime, etc.) and the duration of new medications (a set period of time or forever)
  • Any potential side effects from the medications
  • Medication refills

Helping You Take an Active Role in Your Health Care

By involving you and your family in setting goals for recovery and independence, our transitions of care program increases your chances for a smooth recovery and enables you to take a more active role in planning your health care.

To reach a Health Coach at any time, call 1-800-ASK-BLUE (1-800-275-2583) (TTY/TDD: 711).

 

Diana Lehman, BSN, RN, MBA

About Diana Lehman, BSN, RN, MBA

As Director of Case and Condition Management at Independence Blue Cross, my primary goal is to implement care management programs that improve the health and wellness of our members. In this role, I oversee many registered nurse health coaches and social workers who assist individuals in managing their health. I have been at Independence for over 30 years, and as a registered nurse myself, I am extremely passionate about the work we do.