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Transitional Care <br />Older frail elders, who suffer from a variety of health caze problems often need services <br />from a variety of sites and professionals. <br />During these transitions they are at risk for medication errors and not receiving right <br />services. This may precipitate a visit to the ER or a hospital stay where further errors may occur, <br />Upon leaving the hospital the elders may not understand how to manage their health care <br />conditions or who and when to call. Poorly managed transitions can lead to physical and <br />emotional stress for both the individual and their caregivers. During a transition, the individual's <br />preferences or personal goals my not be passed on to the next setting. This often results in the <br />important elements of the Care Plan "falling through the cracks." <br />Suggestions for the Patient and Caregiver: <br />- Keep a personal file of important health information and show to each new health <br />professional. Keep a list of your health conditions, names and Qhone numbers of your <br />healthcare professionals, medications you are taking, and any aller ies that you have. <br />- Take charge of your medications (both prescribed and over-the-counter) and know why <br />you take each one, how to take each one, and any possible side effects to watch for. <br />- Make sure you understand what services you will get at each new setting and how these <br />will benefit you. Let people know your preferences and ask that they are part of the <br />overall plan. <br />- Bring a friend of relative with you to act as an advocate. <br />- Before leaving each health care setting, make sure you have the name, telephone number, <br />or email of the professional you should contact if ,you have a problem, questions, or your <br />condition worsens. <br />- Before leaving each setting ask what type of follow-up care you will need and how this <br />will be scheduled.. <br />- Knowing what Medicaze (and any other insurances you have) covers is a positive step <br />toward making sure future transitions go smoothly. <br />- Before leaving, aslc what type of follow-up care you will need and how it will be <br />scheduled. <br />The .Jolm A. Hartford Foundation defines the four pillars as: <br />1. Patient or caregiver lmowledge about medication and has a medication management <br />system.. <br />2. Patient and/or caregiver understands and utilizes the Personal Health Record to facilitate <br />communication and ensure continuity of care across providers and settings. The PHR is <br />managed by the patient and/or caregiver, <br />3. Patient and/or caregiver schedules and completes follow-up visit with the primary care or <br />specialist physician and is an active participant in these interactions. <br />4. Patient and/or caregiver is laiowledgeable about indicators that suggest his or her <br />condition is worsening and how to respond. <br />S(~ <br />www.carelransitions. orb <br />www.caregivina.ora <br />www.medicare.aov <br />