Transition Clinic bridges care between hospital, home

Being in the hospital can be overwhelming for patients and their families.

Going home from the hospital can be equally confusing, with information about new medications, activity restrictions, symptoms, future tests and follow-up visits all presented during those few minutes before the patient leaves.

But a new program at King’s Daughters Medical Center aims to reduce the confusion by bridging the care between hospital and home. The new Transition Clinic is a multidisciplinary program that will assist patients (and families) during the first 30 days after hospital discharge.

“Initially the focus will be on congestive heart failure, COPD and pneumonia,” said Sam Adams, M.D., chief medical officer, Inpatient Medicine, with the clinic providing education during the initial post-acute care process.

Depending on diagnosis, Transition Clinic patients will be seen in Suite G20 (Heart Failure Clinic) or Suite G10 (Pulmonary Clinic) of Medical Plaza B, 613 23^rd St., Ashland. Providers include nurse practitioners Lauren Arthur, Suzanne Gilmore, Evie Hill and Donna Holbrook (Heart Failure Clinic) and Anna Bayes (Pulmonary Clinic). The Transition Clinic starts June 1.

The Transition Clinic will help:

• Patients learn about their health condition and lifestyle changes that may be needed to better manage it.
• Reconcile pre-hospitalization and post-hospitalization medications.
• Ensure that patients have prescriptions filled, know what they are for and how to take them.
• Patients find alternatives when they cannot afford their medications.
• Facilitate follow-up visits, lab testing and therapy/rehabilitation.
• Monitor patients’ symptoms and report changes or adverse medication reactions.

The Transition Clinic is an important step in helping ensure that patients receive the high quality, high value care they deserve. “Hospitalized patients are sicker today and have more complex issues than in the past,” Dr. Adams said. “As a result, they are going home with more complex diagnoses, more medications and greater needs than ever before,” he said.

“It’s no longer enough to hand them discharge paperwork and wish them well. It’s the medical community’s responsibility to ensure patients and families have a good understanding of the disease process and how they can manage it and reduce their risk of being readmitted,” Dr. Adams noted.

The Transition Clinic will provide follow-up care for up to 30 days following discharge from the hospital, after which time patients will be returned to their primary care physician or receive assistance in establishing with a primary care provider.

The clinic will function as a resource to patients and assist them in having a successful transition home after a significant illness, Dr. Adams said. In the future, the Transition Clinic will expand its services to assist patients with other complex diagnoses, he noted.

The Transition Clinic was developed through the collaborative efforts of the Inpatient Medicine service, Jennifer McComis, Sandy Smith and the team members in the Pulmonary and Heart Failure clinics.