Tag: Lee Horner

The “What If”: The Downside of Not Using A Communication Platform for Patient Engagement

By Lee Horner, CEO, Synzi.

Lee Horner

Clinician-to-patient communications are typically anchored by in-person, at-home visits. Home health agencies may struggle with understanding the benefits of technology adoption and how it will “work with” traditional check-ins. The downside of not implementing a communication platform unfortunately weakens an agency’s positioning and performance amongst patients, family caregivers, and referral sources. Without being able to safely communicate with patients via HIPAA-compliant messaging, home health agencies may negatively impact their ability to:

Introducing technology into the communications between home health agency staff and patients may be seen as a potential interference to building and sustaining meaningful clinician-patient relationships. However, the use of technology – specifically a communications platform – allows nurses to more effectively perform their clinical responsibilities and more efficiently keep patients engaged in their own care.  The benefits of using technology to strengthen communications are many.

  1. Engaged patients are more invested in their outcomes:  Patients who are engaged in their care are more aware of their day-to-day changes in their condition and more likely to ask their clinician questions if there are emerging concerns and issues. Using a communication platform to reach out to a home health clinician can mitigate trips to the ER and keep a patient on track with the appropriate steps in their care.

A communication platform can help optimize the experience for the patient and the home health agency as all stakeholders can stay in better and more frequent communication during the episode of care. Administrators can schedule and send out timely messages suited to the patient’s condition and care. Ongoing communications include appointment reminders, adherence triggers, and diet/exercise recommendations.

Patients can also safely use the platform’s HIPAA-compliant email, text, SMS, and secure message to reach their home health clinicians regarding questions or issues. The essence of the in-person clinician-patient relationship remains intact during the video-based virtual check-ins. The patient’s family members can also be included in the virtual visits to drive better understanding of the patient’s progress and next steps.  

Data is key to allowing administrator the ability to assess each patient’s level of interaction with each communication and the cadence of touchpoints. As needed, the administrator has the flexibility to adjust the compliance messaging to better engage (or re-engage) the patient. If there are concerns about non-compliance, the home health agency can decide if a more immediate intervention (e.g., call, in-home visit, or transfer to the ED is necessary.

Using a combination of messaging and video touchpoints, a communication platform can help a home health agency increase satisfaction and outcomes for the patient while actively reducing the number, length, and related costs/penalties of hospital stays. The coordinated plan to engage patients throughout the episode of care helps agencies minimize any “what if” scenario for the future of their agency, their reputation, their staff and most importantly, the agency’s impact in their region and community.  

Virtual Care For Chronic Disease Management

By Lee Horner, CEO, Synzi.

Lee-Horner
Lee Horner

The statistics related to chronic disease management are staggering. According to the US National Center for Health Statistics, 40 percent of the US population have chronic conditions and almost one-third of this patient population has multiple chronic conditions. It’s a struggle to manage and engage these patients and keep the “sickest of the sick” at home, receiving care, vs. returning to the hospital or another facility. These high-risk members are also the most expensive. The treatment of patients with chronic conditions accounts for three-quarters of the $2.2 trillion in healthcare spending, with roughly 96 cents per dollar spent in Medicare and 83 cents per dollar in Medicaid, according to the CDC.

Unfortunately, these patients may be “frequent fliers” in a health system; they typically need more attention between care appointments and often rely on emergency medical services and/or the emergency room to answer questions and provide care in non-critical situations. Significant opportunities exist for technology and touchpoints to bring ongoing care and support closer to these patients. Virtual care technology can improve care coordination and increase patient access to convenient care 24/7. Frequent touchpoints can continually engage chronic care patients, resulting in better disease management, improved outcomes and reduced costs.

Post-acute care organizations are embracing the use of a virtual care communication platform to engage chronic care patients and optimize their agency’s available resources. Using a combination of a video-based platform and readily available smartphones, tablets and PCs, home health clinicians can quickly connect, communicate and collaborate with patients – and colleagues — to ensure patients are actively monitored and motivated in their care without a series of in-home visits.

Ongoing messages and a series of virtual visits can augment – and even replace – many traditional in-person visits, effectively reducing the costs and liabilities associated with nurses driving to each patient’s home. The virtual visit can also include a clinician, a pharmacist and even an interpreter, depending on the patient’s needs. During virtual visits, home health providers can use video to detect potential patient issues before an in-person consult is needed and deliver preventive care during the call, minimizing the need for an immediate in-person intervention.

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Leveraging Virtual Care Technology for Efficient Transitions of Care

By Lee Horner, CEO, Synzi.

Lee-Horner
Lee Horner

Care transitions, such as pre- and post-admissions and pre- and post-surgery, are pivotal points for ensuring adherence to the care plan and improved outcomes. However, organizations have historically struggled to keep patient engaged and compliant with the care plan during these transitions – leading to costly re-admissions and poor satisfaction. Virtual care can be applied in these settings to provide an efficient and convenient way to keep the lines of communication open during these pivotal transitions, leading to increased adherence and better outcomes.

Importance of transitional care

A carefully considered transition of care strategy is critical to enabling the safe and timely movement of patients throughout the care continuum. Each transition stage should include the communication of a comprehensive care plan that ensures continuity and coordination of care across points and providers of care. Points of care include hospitals, rehab centers, skilled nursing facilities, long-term care facilities, and even the patient’s own home. Providers of care include clinicians, specialists, nurses, home health workers, in addition to pharmacists, nutritionists, interpreters and transportation assistants.

According to the Joint Commission Center for Transforming Healthcare, sub-standard transitions may result in delay of treatment, inappropriate treatment, adverse events, omission of care, increased hospital length of stay, avoidable readmissions, increased costs, inefficiency from rework and other minor or major patient harm. According to JAMA, failures of care coordination can increase costs by $25 billion to $45 billion annually.

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How Home Health Agencies Can Use Virtual Care with Rural Patients

By Lee Horner, CEO, Synzi.

Lee-Horner
Lee Horner

Rural healthcare organizations and their patients are up against a myriad of challenges, from minimal funding and resources to limited access to care, social determinants of health, and more barriers that stand in the way of effective care delivery. Unfortunately, nearly half of rural hospitals operate at a negative margin and are struggling to survive, according to iVantage’s 2017 Rural Relevance Study.

The number of rural hospital closures has risen to 87 in the last eight years, according to the National Rural Health Association (NRHA). The closures create a large gap in healthcare resources available in rural communities, as the residents cannot always drive or fly great distances to access needed care. Virtual care technology can address gaps in care and help rural providers continue to deliver care for the vast populations and geographies they support.

Increased re-admission rates amongst rural patients are driven by inadequate care and support after the patient returns home. Home health organizations now play a critical role in helping hospitals reduce these rates by providing care to rural patients, especially during the initial thirty days after discharge. Home health organizations are actively implementing virtual care platforms to automate the post-discharge follow-up with a rural patient by sending reminders to schedule appointments for post-discharge virtual visits via the communication channel of the patient’s choice – e.g., text, SMS, email or even a phone call. Follow-up care can be provided in a cost-effective video call (for home health providers and patients) which optimizes the caregiver’s productivity by minimizing excessive transportation time, travel costs and related liabilities typically associated with driving to/from patient homes.

To help home health agencies, there has been a longstanding Medicare rural add-on for home health services. Federal add-on payments through the Center for Medicare and Medicaid Services (CMS) have been crucial to these agencies operating in rural regions of the country. The 3 percent payment modifier to reimbursements for services provided in rural and underserved areas helps these agencies which face higher overhead expenses through factors such as increased travel time between patient visits and demands for extra staff. This payment modifier is imperative so that rural agencies will be able to keep their doors open and provide necessary care to home-bound patients.

However, the Centers for Medicare & Medicaid Services (CMS) has proposed payment rules which may impact the delivery of home health care in rural communities. The shift was mandated by the Bipartisan Budget Act of 2018. Under the new methodology, CMS is varying add-on amounts depending on a rural county’s home health utilization, population density and other factors. Unlike the current standard of a 3 percent three percent rural add-on, CMS’s proposed payment rule segments counties into “high utilization,” “low population density” and “all other” categories:

High-utilization counties are “rural counties and equivalent areas in the highest quartile of all counties and equivalent areas based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under part A of Medicare or enrolled for benefits under part B of Medicare only, but not enrolled in a Medicare Advantage plan under part C of Medicare.” Low population-density counties are designated due to their population density of six individuals or fewer per square mile of land. The all-other category includes counties and areas that don’t fit into either definition.

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How Virtual Care Can Address Healthcare Workforce Shortages

By Lee Horner, CEO, Synzi.

Population growth and aging continue to be the primary driver of increasing demand for healthcare services. According to a March 2018 study by the Association of American Medical College, between 2016 and 2030 the U.S. population is projected to grow by close to 11 percent, from about 324 million to 359 million.

The population aged 65 and over is estimated to increase by 50 percent while growth for the 18 and under age segment is forecasted at only 3 percent. Since seniors have much higher per capita consumption of healthcare than younger segments, the demand for services used by seniors is estimated to far outpace the demand for pediatric care.

Given the expected demand from this demographic shift, the healthcare industry will face growing staffing challenges – with predictions including a shortage of 120,000 doctors by 2030, and a lack of 446,000 home health workers and 95,000 nursing assistants by 2025. Technology – specifically virtual care platforms – can address these expected gaps by allowing providers, care managers, and visiting nurses the ability and flexibility to treat more patients virtually. With virtual care platforms, healthcare organizations can meet the heightened demand for access to care by increasing staff productivity and optimizing workflows, while minimizing costs for all stakeholders.

Increasing Staff Productivity
Virtual care platforms can help administrators optimize their available staff around patient needs. Instead of needing to hire additional team members (or outsource some of the care responsibilities to other healthcare delivery organizations), administrators can review when patients are more likely to seek out care and then match provider scheduling around patients’ preferred timing for virtual visits.

If necessary, staff can also be augmented by remote team members to address an anticipated near-term shortfall of providers. Many health systems – whether rural/remote or urban/suburban locations – struggle with being able to have behavioral health resources on-hand, all the time. Virtual care platforms help remote behavioral health specialists more efficiently provide needed diagnoses and admission/transfer decisions to their onsite colleagues.

Optimizing Workflows
Virtual care platforms can be designed to automate existing workflows and can be readily applied across roles, settings, and facilities. This ensures that the use of the technology is complementary – not disruptive – to how providers currently interact with their colleagues and engage with their patients. Greater collaboration will stem from providers being able to more easily access remote specialists for a video consult. The transition of care – including transfers between departments, floors, providers and settings – will be streamlined as all stakeholders (including the patient and family members) are included in the video-based call to align on expectations and next steps.

Minimizing Excess Costs
Technology enables healthcare organizations to leverage staff to care for more patients, around-the-clock. Instead of expending “windshield” time to physically reach at-home patients for an in-person visit, providers can convert “drive time” to “patient time” and effectively see more patients, more often. Virtual care platforms can fill expected workforce gaps by allowing providers/care managers/home health staff the ability to treat three patients virtually in the time it takes for one at-home visit.

Investment in expanding the number and type of staffing resources would not be needed. In addition, transportation costs and related liabilities associated with driving to/from patient homes and conducting in-person appointments are effectively reduced.

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Telehealth: The Tipping Point of Virtual Care Platform Adoption

By Lee Horner, CEO, Synzi.

Lee Horner
Lee Horner

While telehealth has been around for years, virtual care technology is emerging as a powerful tool that goes beyond the traditional telehealth model. What will it take to reach the tipping point of virtual care adoption?

To become the “next generation” of telehealth, virtual care will need to improve access, availability, application, and acceptance considerations. Virtual care is poised to be embraced by the healthcare ecosystem, helping to optimize satisfaction and outcomes for all.

Access

Timing is everything in critical care situations. Providers need instant access to specialists who can make vital diagnoses and decisions on-demand. Virtual care technology enables specialists to provide an immediate consult via video and ensure that patient questions and emerging conditions are addressed. Remote video-based consults allow a specialist to examine and diagnose the patient in real time, regardless of the specialist’s location. Virtual care will move into the mainstream as more providers (whether at a healthcare facility or home health agency) realize they can obtain timely answers, prevent return trips to the ED, and minimize readmissions. Smaller and rural hospitals will be able to strengthen their role in the community by using virtual care to access offsite, specialized staff.  The time-to-treatment will be reduced; providers will not need to waste precious minutes attempting to contact available specialists. And, specialists can provide the needed consult via video, without needing to rush to the patient’s bedside.

Availability

Many patients fail to follow up with their provider for post-discharge care. No-shows may result when a patient is unable to leave his/her residence due to a medical condition. Some patients are unable to secure reliable, timely, and/or affordable transportation to a follow-up appointment. Virtual care will improve the standard of care by providing patients with more convenient, comfortable, and cost-effective access to follow-up care. Once out of the hospital or nursing facility, a patient can participate in virtual visits on commodity devices such as tablets and smartphones.

Application

Healthcare organizations typically pilot the use of virtual care in one department, with one use-case or for a specific patient population, before rolling out the technology across a facility, health system, and/or health plan’s member base. Organizations may hesitate to expand virtual care across departments if they anticipate the implementation may be disruptive to their current processes. However, virtual care technology is designed to complement (and even automate) current workflows. Providers jump on the virtual care bandwagon when they realize that the application factors in a patient’s choice of communication devices (e.g., tablet, smartphone, and computer) and language.  Because the technology features the ability to include interpreters in a video call and also provide messaging in the patient’s primary/preferred language, more healthcare organizations will accelerate the deployment of virtual care as they can now engage all patients in their care and across any level of connectivity.

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How Virtual Consults Can Benefit the Emergency Department

By Lee Horner, CEO, Synzi.

Lee Horner
Lee Horner

In urgent care situations, being able to provide timely and quality healthcare is essential to the impact and satisfaction of the ED staff and related EMS team members. Using telehealth, current ED workflows can be enhanced to increase access and make collaboration between onsite providers and offsite colleagues and specialists easier and more timely. Virtual care platforms can rapidly improve the delivery of care, effectively addressing urgent patient needs while reconciling the gap in having available specialists on-hand / in-person for immediate consults. Virtual consults are a viable and valuable solution to helping improve outcomes in emergent care situations.

Providing Critical Care On-Demand in the ED

Seconds and minutes count in the ED. With a virtual care platform, a hospital’s ED staff can quickly access remote specialists and facilitate a virtual consult between offsite specialists and patients. Instead of losing crucial minutes, hours, or even critical days in the ED to call a specialist or wait for an in-person consult, ED staff can quickly reach the first available, designated specialist who can deliver a timely virtual consult and provide guidance as to diagnosis, admission, and/or transfer. With virtual care technology, specialists can provide the needed consult from anywhere and on any device. Key decisions as to whether the patient needs to be admitted, transferred or discharged can be made in minutes (vs. hours or days). The costs involved with keeping a patient in the ED are also contained, and the hours or days which a patient spends in the ED are reduced. As hospitals struggle to have multiple specialists on-hand at any time, virtual consult platforms can empower hospitals to leverage specialists within their networks to support their patient care objectives around-the-clock.

Reducing Waiting Time and Minimizing Leakage in the ED

Virtual care platforms are also being used to reduce waiting times in the ED and deliver routine care to patients with non-emergent conditions. In a recent study published in Telemedicine and e-Health, rural hospitals using telehealth reduced the time between patients entering the ED to receiving physician care, according to University of Iowa researchers.

Virtual care had decreased door-to-provider time by six minutes. The researchers also concluded that the length of stay in the ED of the initial hospital was shorter for patients who were eventually transferred but had initially participated in a virtual care consultation. At New York-Presbyterian/Weill Cornell Medicine, the Express Care program allows patients with minor injuries or non-life-threatening symptoms to be seen virtually by an offsite provider via video. When asked by the Wall Street Journal, “What’s the number one complaint of patients in the emergency room?” Rahul Sharma, the emergency physician-in-chief at Weill Cornell, responded: “Wait time.”

The hospital reported that the Express Care telehealth program has cut the average wait time in the hospital’s ED by more than half; between 35 to 40 minutes. As hospitals struggle to prevent leakage and minimize the chance of patients leaving their ED waiting room for another healthcare setting, virtual consults can help the waiting patients access the diagnoses and care they need in a more timely and convenient manner.

Expanding Impact into the Community

ED staff can also use virtual care platforms to expand their impact within their respective communities.  Rural hospitals face some of the biggest deficits in terms of having a range of specialists on staff. Providers in these hospitals can have access to a greater pool of specialists who can support urgent patient care via video when a particular specialist is not already on staff or readily available in-person.  Giving ED staff the ability to facilitate virtual consults on-demand improves their impact within their own community – regardless of distance between the ED and the specialist. ED staff can also conduct HIPAA-compliant virtual meetings to drive better collaboration amongst the broader care team across the care continuum. Communication can be maintained with the appropriate care team members (including the patient’s PCP, a pharmacist, a coordinator at the next care facility, etc.) to ensure the patient’s overall health needs are regularly discussed and addressed in the ED and during the transition of care – without requiring care team members to drive to/from meetings at different locations and facilities.

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How Telehealth Can Deliver Better Mental Healthcare

Guest post by Lee Horner, president, Stratus Video.

Lee Horner
Lee Horner

One of the largest barriers of delivering mental healthcare is the critical shortage of mental health professionals across the country, despite the significant prevalence and impact of mental health conditions. The National Alliance on Mental Illness and the National Institute of Mental Health report that 1 in 5 Americans live with a mental health condition and more than half of American adults with mental illness did not receive treatment in 2016. The U.S. Health Resources and Services Administration estimates an additional 70,000 mental healthcare providers are needed by 2025 to meet the expected growth in demand. In Chicago alone, patients may wait upwards of 10 months for a psychiatrist appointment.

Timely and quality behavioral healthcare is essential for improving patient mental health outcomes and increasing provider satisfaction. Telehealth is emerging as a viable approach to traditional on-site care methods, as it can rapidly improve the delivery of care by effectively addressing patient needs while reconciling the workforce gap. Specifically, telehealth can allow for immediate consultation (especially crucial in time-sensitive situations), increased treatment capacity and collaboration across the continuum of care, and improved outcomes (especially by allowing patients to receive care in the comfort of their own home).

Increased Access to Care
In a given year, approximately one in 25 adults in the U.S. experiences a serious mental illness that substantially interferes with, or limits, one or more major life activities according to the National Institute of Mental Health. The American Journal of Psychiatry reported that untreated mental illness is estimated to cost approximately $100 billion annually in lost productivity.

Patients can benefit from providers who use video-based technology to conduct “virtual consults” when providing an initial diagnosis, as well as making recommendations for admission, treatment, transfer, or discharge. Additionally, for ongoing treatment, video offers patients a way to participate in ongoing care and support via “virtual visits” with mental healthcare providers. Convenient access to care can help patients who may avoid seeking initial mental healthcare and/or ongoing treatment as some patients may unfortunately avoid visiting a nearby mental health clinic or provider for a needed diagnosis if they are wary of public recognition and social disapproval. Patients might also not adhere to scheduled follow-up appointments if visits to these “known” mental health clinics in one’s community are required.   With telehealth, patients can remain comfortably at home and confidentially receive the care they need.

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Telehealth as a Means of Keeping Care In-Network

Guest post by Lee Horner, president, Stratus Video

Lee Horner
Lee Horner

New applications of telehealth that enhance existing provider-to-provider communications are revealing a new way for healthcare organizations to ensure patient care remains in-network. As hospital M&A activity accelerates and organizations strive to glean the most value from their investments in technology and human resources, telehealth is recognized for its role in keeping communications and care in-network.

Telehealth is increasingly being leveraged to offer providers immediate in-network specialist expertise and to reduce ad hoc out-of-network referrals. These kinds of applications make the in-network choice convenient for providers and patients while driving increased patient engagement and more integrated care across the broader care team.

Providers are seeing that telehealth applications can be complementary – instead of disruptive – to their workflows and provide them with a new approach to practicing medicine via technology.

Immediate Communications with Colleagues

Video-based technology can help providers optimize their current workflows by facilitating faster and more flexible consults with on-demand access to in-network specialists. A provider’s network of experts can be built into the technology, which enables a provider to immediately reach the designated, first available specialist for answers. Instead of wasting valuable seconds and minutes looking for the names and contact information for specialists, providers can use telehealth to expedite provider-to-provider interactions which accomplish the critical objectives of doing what is both right and timely for the patient’s situation.

For example, a provider may be examining a patient and realize that the patient’s condition requires specialist expertise.  With telehealth, the provider can immediately reach out to an in-network specialist. The specialist accepts the virtual consult request, from anywhere and on any device. During the virtual consult, the specialist can evaluate the patient and communicate the appropriate next steps.  All stakeholders – the provider, the specialist, and the patient – benefit from the immediacy, efficiency, and effectiveness of a virtual consult conducted in real time.

The broader healthcare organization (whether a medical practice, a hospital, or a health system) will benefit from an increase in in-network referrals. By leveraging the organization’s network to drive better patient outcomes faster, providers can deliver lasting value for the healthcare organization and enhance its overall reputation.

Increased Patient Engagement

Technology can also help providers optimize their current follow-up processes and easily check in with patients after a hospital stay or outpatient procedure. Providers can use telehealth to offer patients appropriate follow-up care at their own home via video. This allows providers (or providers’ in-network resources) to reach out to patients based on those patients’ preferred contact methods (e.g., email or text) and languages (e.g., Spanish, German, etc.) to remind them of their upcoming video visits. The result is increased patient engagement in their ongoing treatment plan. Travel time, related transportation expenses and appointment no-shows are minimized due to this efficient method of follow-up care.

For example, a provider can facilitate a virtual visit with a patient to ensure understanding and adherence. During a virtual visit, the provider (or related in-network care team members) can evaluate the patient’s progress, answer questions in real time, provide patient education, and re-emphasize the treatment plan – all while the patient stays comfortably at home and the provider remains conveniently in the office. All stakeholders – the provider, the care management team members, and the patient – benefit from timely conversations which can drive better adherence and overall outcomes.

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Telehealth: Engaging At-Home, At-Risk Patients to Reduce Re-admissions

Guest post by Lee Horner, president, Stratus Video.

Lee Horner
Lee Horner

Many healthcare organizations refer to the at-home, at-risk patients as the “sickest of the sick.” Unfortunately, these patients may receive inadequate care and attention after being discharged and often rely on emergency medical services and/or the ED to answer questions and provide care in non-emergency situations. The model for treating these patients and attempting to keep them at-home (and not back in the hospital) has not changed substantially in decades. In an attempt to minimize re-admissions, hospitals may schedule case managers and/or nurses to physically visit these patients at-home in an effort to help the patients stay on track with their adherence.

However, this continuum of care model is not sustainable. The budget and resourcing implications are significant when most of the staff’s time is spent behind the wheel vs. in front of the patient. Significant opportunities exist for telehealth solutions to bring the care closer to the patient — at a more convenient and cost-effective manner for all involved.

Why Reducing Readmissions Matters
From the patients’ perspective, returning to the ED and potentially being re-admitted is disruptive and stressful for patients and family. Patients may be put at an additional risk for hospital-acquired infections and complication. Returning to the hospital can also lower the rate of patient satisfaction and weaken overall outcomes.

From the perspectives of health systems and health plans, readmissions are costly. Since the introduction of HRRP (Hospital Readmission Reduction Program), hospitals that exceeded the national average of readmissions for specific conditions (within the 30-day window) have been penalized by a reduction of payments across all of their Medicare admissions. More than half of hospitals in the HRRP program were penalized the past five years, resulting in $528 million in withheld Medicare payments. Re-admissions can also negatively impact measures in Hospital Compare data, levels of provider satisfaction and the health system’s overall reputation in the community it serves. Re-admissions cost more than $26 billion annually but $17 billion is considered avoidable.

What Happens Today
Keeping at-risk patients at-home is critical to reducing re-admissions and the associated consequences.  Typical discharge programs with in-person appointment schedules often fail the at-home, at-risk patient, the providers, and the healthcare system by insufficiently engaging the patient at the point of discharge and upon returning home. The rates of patients being readmitted are significant:

What happens in-hospital and at-home which leads to this situation? In-hospital experiences can adversely affect health and contribute to substantial impairments during the early recovery period, an inability to fend off disease, and simple mental error. As a result, patients may leave the hospital deprived of sleep, experiencing pain and discomfort, without sufficient nourishment, and with medications which may alter cognition and physical function.

When a patient is discharged, the patient may continue to face physical, emotional and even financial issues, depending on one’s condition, health history and home environment. A patient may be discharged without adequate instructions and information for self-care and follow-up. The patient may be provided with comprehensive verbal instructions but quickly forget the detailed instruction. Written instructions may be provided to the patient but the patient may fail to keep the information handy and/or share the information with family/friends serving as caregivers. Internalizing the discharge program and being able to practice self-care may also be negatively impacted by a patient’s level of English proficiency, health literacy, socio-economic status, gender and cultural background.

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