SSM Health Medical Minute: Transitional care clinic offered to help reduce readmissions

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ST. LOUIS - Nationwide, the goal for most hospitals is to keep readmissions less than 10 percent, which requires many resources for patients. Whatever brought a patient to the hospital in the first place, the goal is to allow patients to heal where they are most comfortable – at home.

At SSM Health St. Joseph Hospital in Lake St. Louis, the team includes a transitional care clinic to bridge the gap between the time of discharge until the patient has an appointment with a primary care physician or specialist. The goal is to help these patients maintain their independence at home and reduce the rate of readmissions.

This is a one-time clinic visit scheduled 48 to 72 hours after hospital discharge that is designed to reduce readmissions for patients discharging home to self-care that are considered high-risk for readmission to the hospital in a 30 days period.

“Often times, these patients are complex patients with a number of medical issues going on," said Dr. Karyn Fowler, Vice President of Medical Affairs and Chief Medical Officer at SSM Health St. Joseph Hospital in Lake St. Louis. "So, what we’ve found is with these complexities, going home and coordinating their care, coordinating all their medications, coordinating their access to care, which is key, and what happens to them, especially in the first 5 to 7 days after they go home, is really important and high yield in keeping them home and not back in the hospital.”

During the visit, nurses will assess the patient and perform vitals, the pharmacist will educate patients on medications and complete a physical medication reconciliation to ensure medications are being taken correctly. A registered dietician will then educate the patient on disease-focused nutrition. Any gaps or barriers are identified during the visit will be addressed by one a provider. At the end of the visit, the patient takes home discharge instructions with any recommended follow-ups to discuss with their primary care physician or specialist and reiterate the importance of attending their appointments with these providers.

“We really worked at the transition of their care, not just from the hospital room, but the transition from the hospital to home in those first few days,” Dr. Fowler said.

Patients are asked to bring in their medications for evaluation. Bring their pill box to fill. The team will find out how to book follow up tests or follow up with doctors who they should get appointments with.

Dr. Fowler said the goal is, “how do you enable yourself to stay home and stay well?”

The SSM Health Medical Minute airs every Wednesday at 7 PM on KPLR News 11 and at 9 PM on KTVI Fox 2 News.​

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