Landing in the hospital, whether it’s planned or unexpected, can be a pretty overwhelming experience. Most patients can’t wait to get back home, but that transition can be overwhelming, too, as you leave the hospital with a headful of instructions, a handful of new prescriptions, and often quite a bit of recovery still ahead of you.
While the transition from hospital to home can be a confusing time, it’s also a critical time for avoiding complications that could land you back in the hospital. That’s why The Portland Clinic has put a process and a team into place to look out for our patients, ease the transition and help you land safely back on your feet.
From hospital to home — we’re with you
When a patient of The Portland Clinic is admitted to the hospital, it doesn’t go unnoticed. We’re notified electronically by the hospital, and our nursing staff monitors your progress throughout your stay. Once you’re discharged, we’re notified again, and that triggers our transition-of-care process.
Within 24 to 48 hours of discharge, every Portland Clinic patient gets a call from one of our nurses to make sure that you understand your discharge instructions, you’ve picked up your meds, you’ve got appropriate follow-up appointments scheduled and you’re doing OK.
At that time, we also decide whether you need to see me for a transition-of-care visit. I joined The Portland Clinic in 2018 as an “ambulatory intensivist,” which means that I help higher-risk patients transition safely out of the hospital (I have 17 years of experience in hospital patient care). “Higher-risk” patients are those who are more likely to have post-hospital complications, whether because they were in the hospital for a serious medical condition or because they have multiple health issues. I try to see these patients in their first week back home — ideally within five days or less.
For healthier, lower-risk patients, our goal is to schedule a follow-up visit with their primary care provider within five days, but if that provider isn’t available, I may see these patients, as well.
My first job is to reassure you that I understand what you’re going through. The most reassuring thing I can do is to perform an intensive review of your chart and get to know everything I can before I meet you, so that when I walk into the room, you know that I know what’s going on.
During our visit, we focus on three key things:
- Progress: My goal is to make sure that any treatments initiated in the hospital are working and that you’re making progress as expected.
- Medications: We go through every single medication and make sure you understand what you’re taking, what it’s for and how to take it.
- Complications: I check for signs of common complications, such as blood clots, infections or pneumonia, so we can catch and treat those before they become serious.
When things go well, I’ll typically see patients just once and then get them back to their primary care doctor. If progress is slow or complications arise, I’ll continue to see patients regularly until they’re stable and safely back in their primary care providers’ hands.
Our patient’s story
I recently worked with a patient who needed major surgery to repair a damaged aortic valve. This patient had several other medical issues that weren’t in good control, so I worked with him for a couple of months before his operation to help him get medically ready for the complex procedure. After a very complicated hospitalization, he was discharged to the care of his family, with several health issues that still needed attention.
I started working with the patient and his family again, right away. They had a great deal of confusion about his new medications — he even had stopped taking an important one, thinking he didn’t need it — so the first thing I did was to review each medication with them. For the next several weeks, I continued to monitor his recovery and make adjustments as needed. In the process, we were able to avert several other potentially dangerous complications, including a couple of infections that we caught early and treated with antibiotics. Without close follow-up, this gentleman very likely would have ended up back in the hospital.
The right size to support your recovery
Post-hospital transition of care is so important that Medicare now encourages providers to offer it. Many do, at some level, but having previously worked at a large institution, I see definite advantages to The Portland Clinic’s well-defined process.
We’re able to do post-hospital follow-through very well, partly because of the size of The Portland Clinic: we’re big enough to have the extra support that makes this possible, and small enough to have the agility to adjust things quickly when needed. Driving all of this is the clinic’s commitment to continuing to evolve to meet the needs of our patients at all points in their medical journey.
A great deal happens during any illness, and especially one that requires hospitalization. It’s gratifying to ensure not only that patients and families get the care and support they need, but also that they clearly understand the medical situation and the reasons behind their treatment plan. That way we all can work together as a team toward the best outcome.
