Southington Care Center patients who have been discharged following short term rehabilitation from surgery or injury have appreciated hearing a friendly voice on the phone checking to see how they are settling in at home or a step-down healthcare setting. The care center’s director of transitions makes the calls to identify problems and ensure that discharge services and resources are engaged for a seamless and successful segue.
The care center’s transitions team starts working with short-term residents from the day of admission to identify potential needs upon discharge. Social workers and nurses assist with arranging appropriate services whether long-term care, assisted living, adult day programs or short-term home care needs. They work closely with patient and family to put an individualized “safety net” in place, providing the safest transition.
The callbacks provide the opportunity to review the patient’s medical issues, medication and if any problems have occurred. Questions may include: “How are you feeling?”, “Has a home care aide or therapist visited?”, “How have your medical appointments gone?” and “Do you have any concerns?”
Southington Care Center staff said the former patients have appreciated the callbacks, saying they like the personal touch and being able to ask questions.
Most importantly, additional problems such as medication not being taken or missed medical appointments have been identified and corrected. Often the patient and family are connected with Hartford HealthCare Center for Healthy Aging to identify essential community resources to ensure a better quality of life.
Thanks to transition planning and the followup phone calls, individuals can stay in better health and out of the hospital.
For more information, call Southington Care Center, 860.621.9559.