Families often find themselves in crisis situations when a loved one is suddenly hospitalized with an unexpected illness or injury. Unfortunately, when individuals are discharged from the hospital and return home, they often have little or no knowledge about the medications they’ve been prescribed, how to obtain their medications, and do not schedule a follow-up visit with their primary care doctor even when recommended by the hospital. Research shows that without proper discharge planning, many former patients find themselves readmitted to the hospital within 30 days. This can create chaos for patients and their families, especially when family members live far away.
At Feinberg Consulting, our Care Managers assist families who have a loved one in the hospital. Our goal is to lessen the chance of re-hospitalization once the patient has been discharged. We act as a liaison between patients, their families, physicians and hospital personnel to ensure that your loved one’s diagnosis, test results, medications and individualized treatment plan are carefully outlined and understood upon discharge from the hospital. We provide personalized guidance for families, advocating for their hospitalized loved one and assisting both patients and their families with the discharge process and treatment once back home.
Pam Feinberg-Rivkin, RN, CCM, CRRN, ABDM, and Heydie Collazo, MSW, have received specialized training from Eric Coleman, MD, MPH, at UC Denver specifically addressing the use of a Personal Health Record, Medication Reconciliation, Red Flags and follow up with the Primary Care Physician (PCP). Patients with complex care needs receive guidance, tools and self-management techniques to ensure that their needs are met during the transition from the hospital or skilled nursing facility to home. Patients feel empowered by their ability to self-manage their own healthcare needs. While a home care nurse’s responsibility is to provide direct healthcare and educate the patient, a Care Manager has the ability to go above and beyond to ensure the patient is safe in their environment and that the prescribed treatment plan is followed closely by the patient and caregiver. As a Transition Coach™, Heydie Collazo, MSW, coaches the patient directly as well as their caregivers on providing self-management skills to their patients.
Our Readmission Management Program (RAMP), designed to provide safe discharge and follow-up with the treatment plan, includes 24-hour Telehealth in the home to monitor a patient’s vital signs applicable to their condition or disease. This monitoring enables the Care Manager to be in contact 24/7 with the patient and their caregiver for increased communication and stability in their home environment.