Katie Sciba

Katie Sciba

“I thought this was going to be the golden years,” he said, and we chuckled together as we discussed his constant back pain and other health problems. “Maybe you still have some golden moments, especially outside with your chickens or cows.” As I asked him how he was managing everything (after being discharged from home health in July), he said fine. He said he really didn’t know how he would be managing if he hadn’t had home health. When I asked him why, he said he just wants to stay in his home, and by having nurses, therapists and a social worker help him figure out how to manage his health, he has been able to stay home. The last thing he wanted was to go back to the hospital.

Care transitions

Have you been to the hospital lately? How was your transition home? Did you feel confident to go home? Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days. This translates to approximately 2.6 million seniors at a cost of more than $26 billion every year. Readmission rates are also high for patients covered by Medicaid and private insurance.

People with terminal illnesses and multiple chronic medical and mental health conditions are most at risk, especially if they have fragile support systems in the community.

Home health care

Citizens Medical Center Home Health supports the hospitals and the patients, providing care coordination and patient education that ensures patient comfort and safety and builds patient confidence in self-managing care at home.

  • Standardized care management process provided by a professional trained to perform critical activities that empower the patient/caregiver with self-management skills.
  • Through education, Citizens Medical Center Home Healthcare agency encourages family involvement in care, helping them to better understand the condition and monitoring of the disease.
  • Facilitate medication collaboration among health care providers and the patient. Staff ensures medication is taken as prescribed and are trained to recognize and report adverse side effects that could lead to complications.
  • Ensure patients maintain follow-up appointments with physicians.
  • Connect patients to resources in the community.
  • Provide a 24-hour response system. Research has reported that on-call coverage improves care and patient satisfaction. Patients and referral partners have the comfort of knowing someone will be reachable whenever needed, no matter the hour.

Questions for you during care transitions

Where will I get care after discharge? Do I have preferences? Am I ready for the following activities: bathing, dressing, using the bathroom, climbing stairs, cooking, food shopping, house cleaning, paying bills, going to the doctor and picking up prescriptions?

What is the my health condition? What can I do to improve? Who will perform other tasks that require special skills, like changing a bandage or giving a shot?

Are there problems to watch for? What should be done if problems arise? Would working with a social worker help the patient and his or her family better cope emotionally and financially with the patient’s illness?

What drugs, vitamins or supplements should I be taking? Should I be following a special diet? Will I need medical equipment? Who will arrange for this?

  • Home care providers will travel about 8 billion miles to deliver the best health care in the world.
  • Ninety percent of Americans want to age in place, and home care is the preferred method of health care delivery among the disabled, elderly and chronically ill.
  • Home care provides high-quality, compassionate care to more than 5 million Americans annually.

Katie Sciba is a social worker, a writer and the administrator for Citizens Medical Center Home Health.

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