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Q: My facility is working with home health agencies to improve discharges. How can we smooth patients’ transition to home? 

A: When transitioning care, the first step is ensuring the next provider can adequately care for the patient. Make sure any home health partner can see the patient soon after discharge, preferably within 24 to 48 hours. 

Home health agencies also must have enough information and resources to meet the patient’s needs. You’ll need to verify equipment, medications, treatments and follow-up appointments. 

Durable medical equipment. Ensure equipment is ordered and has been or will be delivered. This includes items like wheelchairs or beds, but it may also include medical devices for treatment. 

Medications. Upon discharge, ensure  home health receives the medication reconciliation. Additionally, ensure patients can get their medications, noting any finance or transportation issues. Address this prior to discharge and express any concerns to the agency. 

Treatments. Ensure supplies have been ordered and delivered. Wound supplies, nebulizer supplies, CPAP/BiPAP supplies, blood glucose monitoring supplies and more may be necessary in the home. 

Follow-up appointments. When possible, schedule and alert home health to any follow-up appointments. Making the appointments for the patient improves chance of attendance. Ensure the patient has transportation or arrange it. 

Finally, call the patient and/or caregiver within 48 hours to ensure home health has seen them. Confirm the patient has received all the above items and answer follow-up questions. Easing the transition can assure needed care continues even after the patient leaves your facility.