IN GOOD HANDS:
Diana Luke appreciates the
follow-up care she is receiving
from a Residential Home Health
Avoiding hospital readmissions through community partnerships
When Diana Luke left the hospital, she was ready to head straight down the path to recovery. However, her road to wellness turned out to be a bit rocky—and she found herself back in the hospital within a week.
That’s when her daughters and Botsford Hospital staff stepped in. They found her the coordinated care she needed to get better, go home, and stay home. That care came from a partnership between Botsford and Residential Home Health.
Residential works with hospital discharge planners, sending a registered nurse (RN) to the patient’s home or other care facility within 24 hours of discharge. They then can deploy telehealth services to monitor daily vital signs and provide additional support and education to the patient and family, as well as proactively follow up with the primary care physician.
Bridge to Home
A new Botsford Commons Bridge
to Home program provides another
alternative for patients leaving the
hospital. The program offers patients
a fully furnished suite in the senior
living complex, three meals a day,
and daily housekeeping--along with
referrals for therapy and coordination
of other health care services.
"This allows us to stabilize a
patient’s care and be sure they
are fully able to go home,” says
Diane Zide, executive director of
operations, Botsford Commons.
Are you, or a loved one, making
this transition? Get more
information about Bridge to Home.
Call (248) 426-6903.
Making transitions easier
These services began to benefit Luke as soon as she got home. “My husband and I had trouble understanding some of the hospital discharge orders,” she says. “But all we had to do was call the RN, and she explained everything. She did a great job teaching us all we needed to know about my care.”
Luke also took advantage of the telemedicine service. The easy-to-use equipment allowed Luke to monitor her vital signs. The information was then sent electronically to her nurse. If something was awry, the nurse would call right away and advise Luke on what steps to take. “I think telemedicine is what made me look at myself honestly and change my lifestyle,” Luke says.
Those changes paid off. No longer on insulin, Luke has been also able to stop using oxygen during the day. Perhaps most importantly, Luke received the education and monitoring she needed to change her behaviors and keep her from returning to the hospital.
Diana Luke's illness didn't affect just her. "They brought her back from the dead," says her daughter Kim Kleinlein.
Go to www.botsford.org/blog to read Kleinlein's side of the story.