Referral Guide Vol. 1 Issue 2
Guide to Senior Care Options & Patient Care Assisted / Alzheimer’s – Home Healthcare – Hospice – Home Care Private Duty Nursing - Skilled Nursing & Rehabilitation – Rehabilitation Hospital MOBILE AND DIGITAL AVALIABLE
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We will get your patients home again, faster and stronger.
Chef-prepared meals, private suites and personal concierge service. This is rehab? Our Home Again rehabilitation program will pamper your patients while they undergo therapy following surgery or illness. Once they are ready to return home, we will provide them with a unique Personal Wellness Plan to educate them on their diagnosis and reduce their chances of being re-admitted to the hospital. To find out how we can help your patients transition smoothly back home, call us to schedule a personal tour.
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For a full list of our Ohio locations, 2 please see the facing page. Call a campus near you for more information about their services.
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Making a Difference in Patients' Lives
Hospice of Southwest Ohio shares successes with a variety of programs they offer hospice patients. Hospice is a word that can strike Hospice a word can strike fear and loss inis the heart that of a lovedfear and loss in the heart of a lovedone.one. TheThe word generally implies thatthat word generally implies the end is near for a loved-one, and the end is near for a loved-one, and lying on their death theythey are are lying on their death bedbed withwith perhaps only days or weeks to live. perhaps only days or weeks to live. Hospice does not have to be a negative Hospice does not have to be a doom and gloom experience. It can be negative doom and gloom a positive experience for experience. a family, where memories are made,experience and the patient It can be a positive for in a need of care is in a comfortable environment family, where memories are made, and with quality care and opportunities to enjoy the patient in need of care is in a precious time with loved ones. comfortable Hospiceenvironment of Southwest with Ohio quality is working caretoand opportunities to enjoy change the perception of Hospice care. They offer edge services precious timecutting with loved ones. to meet the needs of the wide range of patients they see. Hospice of Southwest Ohio is In their most recent survey performed by PLEASE SAY “I FOUND YOU IN
working to change the perception of the state, HSWO received a 100%, 0 Hospice care. They offer cuttingwith edge deficiencies. service to meet the needs of the wide A new inpatient center for hospice range patients see.beginning In their most patientsofset to openthey at the of recent performed state, October.survey The facility will offer by ninethe beds and increase the quality a of 100%, care for with patients HSWO received 0 who have pain and/or a symptom to manage that deficiencies. is uncontrolled. Located in Madeira, Ohio, A new inpatient forlocated hospice HSWO’s Care Center iscenter centrally for easy access.opened last October. The patients Part offers of Hospice of Southwest facility nine beds with andOhio’s success is duequality to the variety of programs they increased of care for patients offer their hospice patients. who have pain and/or a symptom to “We try to provide whatever services the manage that is Located families need,” saiduncontrolled. Joe Killian, CEO. “We in Madeira, Ohio, HSWO’s Care Center have teams that look at and examine all the is different variables programs we offer centrally locatedforfortheeasy access. to make life easier for patients and families.”
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Part of Hospice of Southwest Ohio’s success is due to the variety of programs they offer their hospice patients. “We try to provide whatever services the families need, “said Joe Killian, CEO. “We have teams that look at and examine all the different variables for the programs we offer to make life easier for patients and families.” Hospice of Southwest Ohio has created a subsidiary company, CareBridge Palliative Care Services. This program originally founded as a non-profit provider of symptom therapy treatments and has grown to one of the Cincinnati’s largest providers of symptom management services. The primary goal is to help loved-ones, and family members regain control by establishing an action plan to reduce pain and suffering. In addition to CareBridge, Hospice of Southwest Ohio has several hospital based palliative care symptom management programs. They also have taken advantage of the benefits of telemedicine. The technological advances allow hospice
patients to be monitored around the clock. With this cutting edge technology, a nurse still make the same number of patient visits, but the patient’s status can be monitored inbetween visits via IVR (Interactive Voice Response) or with stationary monitors. The IVR will tell a patient to step on the scale and record their weight or remind them to take their medicine and tell them which pill to take. Stationary monitors are used for bed bound patient who are unable to move around. It service the same purpose. A bed bound patient would be reminded to take medicine, record blood sugar or blood pressure, all vital information that can fluctuate. All patient information is reported instantaneously to caregivers who are able to send out a nurse a head of potential problems. This cutting edge technology allows patients to be monitored without the disruption of another person being in and out of the home. “We can know when to send someone out without waiting for a phone call, “ Killian said.
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Another remarkable service offered by Hospice of Southwest Ohio is their Make a Memory Programs. Thanks to the help of volunteers and the dedicated team at Hospice of Southwest Ohio, patients can enjoy a special day with loved ones making memories. They offer several options to their patients and go to considerable lengths to ensure the health and safety of the patient while making memories. Memories can be made relaxing and being pampered at a spa or taking in a Reds or Bengals game. The following testimonial from a patient’s daughter illustrates Hospice of Southwest Ohio doesn’t look to just serve medical needs, but really aims to the highest level of care, making this experience the best it can be within our capabilities. When Mom and I chose Hospice of Southwest Ohio, we took advantage of several special programs that helped us better understand and celebrate the hospice journey. It’s just one way Hospice of Southwest Ohio goes above and beyond standard hospice care.” Music ministry, Pet Interaction, Licensed massage therapy, Life Disc and Bereavement Support are just a few of the programs that Hospice of Southwest Ohio is pleased to offer that enhance quality of life for patients and provide support for family and caregivers. For more information about Hospice of Southwest visit www.hswo.org or call (513-770-0820
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ELIMINATE HARM ACROSS THE BOARD Days Since Last Readmission READMISSIONS PREVENTION:
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Conduct enhanced admission assessment of discharge needs and begin discharge planning at admission
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Conduct formal risk of readmission assessment; align interventions to patient’s needs and risk stratification level
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Perform accurate medication reconciliation at admission, at any change in level of care and at discharge
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Provide patient education that is culturally sensitive, incorporates health literacy concepts and includes information on diagnosis and symptom management, medications and post-discharge care needs
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Identify primary caregiver, if not the patient, and include him/her in education and discharge planning
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Use teach-back to validate patient and caregiver’s understanding
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Collaborate with post-acute care and community-based providers including skilled nursing facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative care teams, hospice, medical homes, and pharmacists
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Before discharge, schedule follow-up medical appointments and post-discharge tests/labs; for patients without a primary care physician, work with health plans, Medicaid agencies and other safety-net programs to identify and link patient to a PCP
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Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of after-hospital care plan using teach-back and identify any unmet needs, such as access to medication, transportation to follow-up appointments, etc.
Send discharge summary and after-hospital care plan to primary care provider within 24 to 48 hours of discharge
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HOSPICE
Compassionate. Efficient. Correct.
And right now. When case managers have a problem. VITAS is the answer. When your concern is the frailest of your patients, VITAS has your back. Calling VITAS can reduce lengths of stay, end rehospitalization, and do the right thing for patients and families. Call us for a hospice evaluation; we’re always available.
Referrals: 1.800.93.VITAS VITAS.com
VITAS makes accessing hospice clinical criteria and referrals incredibly simple with our FREE app. Just scan the QR Code and follow the instructions to download the app.
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