I have participated in two transitions in care with my mother. The first was when she was released from the hospital after undergoing neurosurgery for a malignant brain tumor. Immediately after surgery of her brain tumor, she went through two weeks of intensive physical, occupational, and speech therapy. At the end of this period, the recommendation was clear. She required around the clock supervision. The plan was to send her home where a trusted family friend would move in with her, and she would continue to receive therapy through Visiting Nurse Services.
Her insurance allowed for home care services, and ongoing therapy. Soon after bringing her home, while I was in the kitchen preparing lunch for her, she fell in the living room and hit her head. Thankfully, no damage was done. Two hours later, the visiting nurse arrived, and began to interview my mom. My mother in incredibly articulate fashion described how she was not a fall risk and even more, that she would be fine with no services. In truth, my mother had difficulty with sequencing; it was difficult for her to perform actions in the correct order, making preparing meals, cleaning for, engaging in personal care without supervision, and attending to financial matters impossible. Had I not been present, the visiting nurse would have come to an incorrect conclusion, and she would not have gotten the care she needed.
As my mother transitioned to radiation therapy and chemotherapy, her status deteriorated requiring another hospitalization to investigate whether there was recurrence of her tumor or an underlying infection. By the end of that hospitalization, it became clear that my mother required a nursing home for the safest care. I accompanied my mother to the nursing home where I found that I needed to assist the nurse in deciphering the discharge summary, and to clarify for her who her newest patient was. A picture of who my mother was via the discharge summary was inadequate to ensure the best care.
Transitions in care have become a critical focus in medical education as the medical profession finds itself increasingly accountable to the public. Poor transitions in care result in unsafe patient care, patients who fall through the cracks, and hospital readmissions. For those patients who lack personal advocates, the medical professional must step into that role. Care must be paid to how we communicate to the receiving health care professionals in order to catch the patient on the other side. However, the pace of inpatient medicine, with its competing duties, does not always allow the physician the time to critically reflect on how that discharge process should best communicate the most salient data to ensure safe passage to the next stage.
At the most recent meeting of the Alliance for Academic Internal Medicine, Dr. Meade from Baystate Medical Center highlighted their educational efforts with internal medicine residents. Residents make the journey with their patients to their next destination to smooth the transition. These experiences help them to appreciate the importance of and communicate a better discharge plan. What a novel idea. Personal epiphanies fuel the importance of keeping patients safe.
Maria Maldonado is Program Director, Internal Medicine Residency Program and Associate Chair of Medicine, Stamford Hospital. She can be reached on Twitter @MMaldonadoMD.
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