Dome - Navigating Transitions of Care

Dome February 2013

Navigating Transitions of Care

Date: February 1, 2013

CAPTION Transition guide Aaron Rash, a nurse with Johns Hopkins Home Care Group, helps patients at risk for readmission and other complications after leaving the hospital by coordinating care with members of their health care team and addressing other di

Transition guide Aaron Rash, a nurse with Johns Hopkins Home Care Group, helps patients at risk for readmission and other complications after leaving the hospital by coordinating care with members of their health care team and addressing other difficulties in managing their care.

Q - What does a typical day look like?

First, I call patients who’ve left the hospital to see how they are doing. I also participate in multidisciplinary rounds at Johns Hopkins Bayview, which gives me a chance to meet patients while they’re still in the hospital, to learn about their situation and be involved in the discharge planning process. Later, I meet with other patients in their homes.

Q - What situations are common after patients are discharged?

Many patients aren’t compliant with taking their medications and following up with their doctors after leaving the hospital. They get out of the hospital and think everything is fine; they don’t realize how important that follow-up is. I make sure that patients are able to get to appointments with their primary care doctors and specialists, in some cases by arranging transportation for them. If patients are doing poorly, I can get them in to see the doctor more quickly or arrange home health services. When patients don’t have a primary care doctor, I help them find one, along with any other community resources they may need.

Q - What other tasks do you help with?

I check to see whether patients are running low on their medications and if they need help getting their prescriptions refilled or getting enrolled in a medication assistance program that helps cover costs. Educating patients on how to manage their health condition is another important aspect of my job. For instance, I may check to see if someone with diabetes knows that the Oodles of Noodles in his pantry contains sugar.

Before leaving, I always ask, “Is there anything else I can do? Do you need me to take your trash out?” If I were at home and sick, I would want someone to do the same for me.

—Shannon Swiger