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Empowering patients through Discharge Management

By: Lindsey Meston, PharmD, Chief Quality Officer


What is Discharge Management?

When you leave the hospital, skilled nursing, or other inpatient facility, it is extremely important to develop a plan for a smooth transition home.  Discharge Management involves in-depth discussions with your care team designed to enhance quality of life, optimize your time while inpatient, and ensure you have the proper care and understanding of any changes that occurred during your stay as you settle back home.  While people often think about specialists when it comes to hospital stays, Primary Care providers play a vital role in this process.


What are the key components of Discharge Management?

One of the first key elements of discharge management includes involving you and your family in the discharge process.  Since the risk of returning to the hospital can occur at any time, a series of discussions may be had about home support, how to take medications, how to identify warning signs, and proper follow up.  Education is also very important to make sure you fully understand any changes that occurred, who you should follow up with, and alerting you to support services in the community if you may need them.  Discharge Management does all of this and more!


Why is Discharge Management needed?

Effective Discharge Management is crucial for your recovery now as well as your health in the future.  Patients with multiple chronic illnesses or complex medical histories are more likely to become hospitalized and may require extensive discharge planning to prevent it from happening again.  Discharge Management often occurs during the first few days at home and through the first 30 days after discharge, as this is the period when readmissions are most likely to occur.


What is Gensis’s role?

Genesis Medical Associates has a multidisciplinary team who provides valuable input to ensure successful transitions home.  As a Primary Care group, we have a team dedicated to engaging patients in shared decision making to create the best care plan moving forward.  Our team ensures your PCP is aware of hospitalizations that occur, informs you of medication changes during your stay, and works directly with providers to ensure continuity of care.  Discharge planning often takes a variety of healthcare professionals such as nurses, socials workers, physicians, and pharmacists. At Genesis our clinical pharmacists and nurses can review your current medications and compare this list with the discharge summary provided by the hospital.  They assess the accuracy of the updated list with you and, based on other labs and results, work with the provider to adjust therapy as needed and address other barriers like cost.

In summary, Discharge Management is a comprehensive, patient-centered process aimed at ensuring smooth and safe transitions back home from inpatient facilities like the hospital.  It involves detailed planning, education, coordination, and follow-up to support patients in their recovery and reduce likelihood of readmission or further health decline.  Discharge Management is meant to make leaving the hospital a seamless process for you and any caregivers you may have.  If you have any questions about your medications, community resources, or your care plan, do not hesitate to reach out to the Genesis team.  Speak to your provider if you have any concerns regarding the process and if there is anything we can do to make you feel more empowered about your health.

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