For Patients and Families
There are many ways for patients and their families to participate in making care transitions as successful and positive as possible. Health care is best delivered by a team and the patient and family are at the center of this team.
What do we mean by Transitions of Care?
Transitional care refers to the coordination and continuity of health care during a patient's movement from one healthcare setting to either another or to home, called care transition, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.
Important things to consider after leaving the hospital...
Even if you are feeling better, it is important to follow up with your doctor after being in the hospital. There is a lot of evidence that following up with your doctor within 3 to 5 days after discharge can reduce the risk of returning to the hospital.
Understand your medications. Frequently medications change after a hospitalization or perhaps you were struggling to understand your medications before you went into the hospital. Ask your health care providers as many questions as needed until you feel confident. It is also recommended that you keep an up-to-date list of medications (Medication List) available for follow up with your doctor. Learn more about the PACT program.
AARP Family Caregiver's Video Guide to Managing Medications
46 percent of family caregivers perform medical/nursing tasks such as changing catheter’s, giving injections, preparing special diets, managing complex medication routines and wound care. These videos are aimed at preparing family caregivers to perform these tasks.
Understand your discharge plan
Ask for help. Most people are anxious to return to their normal routines after leaving the hospital but you may find that you may need more help.
Take a moment to think it through and consider your needs (Preparing To Go Home).
Talk with the hospital social worker or nurse.
Call your local Aging and Disability Resource
Center (Kenosha County ADRC: 262-605-6646).
Resources to support good communication:
Communication is critical!
Advanced Planning for Health Care Decisions
National Healthcare Decisions Day every year on April 16!
Do your health care providers understand your wishes about care? Have you thought about or completed an advanced health care directive?
Talk and plan...do it for yourself and the people close to you. Click here to view a video by Honoring Choices Wisconsin, a major initiative to promote the benefits of and process for advance care planning.
Wisconsin's Power of Attorney for Health Care form is available on line. The Guardianship Support Center also offers excellent resources to further understand the options for completing an advanced directive.
Power of Attorney for Health Care Instructions for Kenosha County for what to do with the document has been developed by the Coalition specifically for Kenosha County residents.
Community support is available to assist you!
Other Resources:
