Patient/Person Centered Care – Seamless Transitions Hospital to Home

I have often asked myself how many elderly and frail sitting in wheelchairs in the hospital lobbies waiting for transportation have the full support they need at home.

The fragmentation of care is particularly evident in patient handoffs – whether they occur within the walls of the hospital, or during a transfer to another department or facility – making them prone to errors….  Joint commission analysis found that 70% of sentinel events were caused by communication breakdown; half of those occurred during handoffs. Another consequence is that patient and their families often feel “lost” in the system….” (PHSA strategic plan 2010-2013)

This quote speaks to movement within the health care system but does not mention those leaving the institutional setting to go home.  I have heard many stories where seniors returned to hospital within weeks of their original stay.  This is a common occurrence and not a fault of anyone…

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