Discharging Patients Home is Complex and Plagued with Challenges
Assessing Patient Help
Organizing Home Services
Discharge Planning, Summary, and Checklist
Providers need to make sure that the patient and their care giver can perform self care activities, eat an appropriate diet, follow up with designated providers, and obtain and self-administer medications.
Visiting nurses, personal care, infusion providers, and other in home services need to be referred to and post-pandemic in home care cases can take up to a week to be successfully opened.
Patients need to be discharged at an appropriate time, with the appropriate services, and signed off from the appropriate providers all while receiving a thorough and easy-to-understand summary of stay.
Discharge education needs to explain: "Why was I in the hospital?" "How so I manage at home?" "What should I do if I run into problems?" "Why is in important for me to do this?"
Discharge teams verify patient and care giver knowledge multiple times by asking questions about a discharge summary and patient instructions: "What is your understanding of your heart problem?"
Teams need to make sure that the patient's biggest responsibility of their own - taking their medications properly - is explained, understood, and that the prescriptions they are leaving with are accurate.
Centennial reduces discharge planner's burden and better supports patients at home
Medications provided at discharge and hand-delivered to patients to their home setting
Medication reconciliation and safety review
24/7 on-call support
Seamlessly integrates into facility workflow
Medication adherence tools and solutions
Clinical pharmacist follow-up
Quality metric analysis, closure assistance, and goal setting
Home-based team follow up and support
The Data is Clear
30-Day Readmission Rate, compared to 21.3% control group
Medication Adherence - Including 98% PDC in cholesterol and diabetic measures
Reduction in ER-Visits
Of Patients Continued to use Centennial for 90-days or more
Implement TransitionCare into Your Facility
Centennial's collaborative approach has let me focus on patient care. Centennial works with us to provide medicines to patients and medication reviews for our charts. They are an asset to our team, every day.