Medical care is essential when moving a patient or client from one care setting to another, such as transitioning from hospital to home. Joanna Robertson, DNP, FNP-BC, PMHNP, at Beachfront Internal Medicine and Mental Health Clinic in Lewes, Delaware, is a hospitalist familiar with the happenings when patients are discharged and settle back home or other care facilities. Knowledgeable and compassionate, she improves patient experience through timely follow-up and care post-discharge. Call the internal medicine and psychiatry practice for more information regarding transitional care or schedule an appointment online to learn more. Telehealth visits are available.
Transitional care refers to when a patient leaves one care setting, provider, or specialist and moves to another, such as:
Changes to patients’ care settings occur as their condition and care needs evolve during an acute or chronic illness.
Joanna Robertson, DNP, FNP-BC, PMHNP can fill the void in lack of follow-up and accessibility of care, especially concerning a patient’s inability to see their primary care physician shortly after discharge from a medical facility.
Joanna Robertson, DNP, FNP-BC, PMHNP understands the challenges and errors that can arise during transitional care. Key root causes of failed transitions and other challenges include:
Beachfront Internal Medicine and Mental Health Clinic works hard to fill any void regarding lack of follow-up, timely care, and accessibility.
Transitional care services address the hand-off period between the inpatient and home. After a hospitalization or other inpatient facility stay (rehab), the patient may be battling a medical crisis, new diagnosis, or change in medication therapy. Care should include:
The period between discharge and the first outpatient appointment is a particularly vulnerable time for patients when adverse events can occur. You might not know where to seek help if a question arises or a new event occurs, leading to patients and families not bringing significant clinical changes to medical attention.
This issue is amplified for patients who can not schedule timely follow up with their primary providers.
Patients may have tests such as lab work requiring follow-up after discharge. Assuring which provider is responsible for addressing follow-up items in a timely fashion is essential for safe release and transition.
Medications, many of which have been changed or started during hospitalization, remain a paramount safety concern, with as many as 50% of patients being found to have a clinically significant medication error after discharge. Medication management can help reduce the risk of falls and infection associated with errors.
Joanna Robertson, DNP, FNP-BC, PMHNP will, when necessary, prescribe medication to manage a range of conditions like hypertension. These medications help lower blood pressure and reduce the risk of complications like stroke and heart disease.
Call Beachfront Internal Medicine and Mental Health Clinic today or schedule an appointment online to learn more about transitional care.