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Ensuring the Right Care After Hospital Discharge

For the past year, Natasha has been the lead VNSNY home care consultant nurse at New York Methodist Hospital in Brooklyn, supervising a staff of four Home Care Consultants (HCCs)—the official title for intake nurses—and three intake associates. Together, this team has the vital job of determining whether patients about to be released from the hospital are ready to return home or need additional inpatient rehabilitation at a skilled nursing facility.

Natasha has worked with VNSNY’s Intake Department at every level: She served as a customer service representative while still in nursing school; then, after graduating and coming to VNSNY full-time in 2011, she moved up the ranks from associate HCC to HCC and later lead HCC. In her latest career step, she was recently promoted to Clinical Intake Manager for Business Development.

In every job she’s held, the rules of intake protocol have been her guide. Each patient must meet a list of criteria in order to be accepted to VNSNY Home Care, she explains, and the role of the patient’s family or caregivers is often critical as well. “When I assess patients, the first consideration is always safety. During a bedside assessment, I have to ascertain whether the patient is able to take care of him or herself independently, and if not, whether they have appropriate family support at home.”

One of her patients, Olga*, had been hospitalized for respiratory distress. “Her family requested that she be discharged home with a ventilator rather than to a long-term care facility,” Natasha recalls. “I explained what that would require—starting with at least two or three family members being educated on ventilator use, suctioning, wound and percutaneous endoscopic gastrostomy (PEG) care, and medication administration.”

The family proved very receptive. “They were willing to do everything that was needed,” Natasha says. “So I arranged for a visiting physician and a vendor.” The vendor provided supplies and a respiratory therapist and also conducted a home visit to make sure the environment was appropriate for a ventilator. Olga was discharged home in care of her family and a visiting nurse, who made an initial visit the day after discharge. “Thanks to the family’s support, the transition to home from hospital was seamless for all involved,” adds Natasha.

Intake evaluations, which are always done in the hospital, may take anywhere from fifteen minutes to over two hours. “We have a strong team of nurses and intake associates at hospitals across our service area, whose job includes documenting a patient’s clinical status based on the hospital’s records,” says Natasha. “Besides helping in our evaluation, this also assists our field nurses when they make their first home visit following discharge.” If a case isn’t complicated, the evaluation may simply require educating the patient on wound care, injection, or other disease management. An elderly patient who has dementia or is bedbound can take more time to coordinate. In situations like these, the family must sign a mutual care agreement stating their responsibility for the patient in the community. If there isn’t sufficient family support, the patient will be discharged to a rehabilitation facility instead.

Whichever path a patient takes, notes Natasha, VNSNY’s home care consultant nurses are there to help the hospital discharge the patient in timely fashion and into the right care, and to help prevent avoidable readmissions. “In the end, our goal is always the same: to transition the patient into the community safely.”

* The patient’s name has been changed for privacy.

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