by Curlan Campbell
- Neglected post-hospitalisation care and poor health/self-care management are main causes for hospital readmissions
- Majority of hospital readmissions are potentially preventable
- 30-days hospital discharge planning and home follow-up programme for people at risk of readmission
For over 11 years, Ambika Joseph served as a nurse at the General Hospital witnessing firsthand the high rates of rapid hospital readmission 3 or 4 days after a patient is declared fit to be discharged.
The transition from being discharged from the hospital to complete recovery at home and patients having to be readmitted shortly after, is a major concern that must be addressed, since the majority of these readmissions are potentially preventable.
This unfortunate situation has prompted her to do something to reverse this trend by focusing on Transitional Care in achieving this type of healthcare reform. However, Joseph had some hurdles to cross and as part of her professional development, she was fortunate to benefit from a scholarship from the Government of Grenada to pursue a Bachelor’s Degree in general nursing from the Department of Nursing & Allied Health Sciences at St George’s University (SGU).
She graduated with honours and was among the first batch of 20 graduates in 2019 who completed the programme launched in 2016. Currently, she is pursuing her Master’s Degree in Public Health with specialisation in Health Policy and Management, to be completed in March 2021. However, in the meantime she has set in motion her plan to establish Grenada’s first Transitional Care clinic. The idea manifested before she attained her bachelor’s degree.
The importance of high-quality transitional care in improving the outcomes of patients has gained increased attention especially during the Covid-19 pandemic where healthcare facilities are expected to be inundated. Transitional care is defined as ‘actions designed to ensure coordination and continuity of care of patients as they move across the different healthcare settings.’ In Grenada, Joseph has identified neglected post-hospitalisation care and patient poor health/self-care management as the main causes for hospital readmissions.
While many complain about the shortcomings of Grenada’s health facilities, Joseph has decided to offer a solution-oriented approach by establishing her clinic.
“I have been inspired to bring into existence an institution called Care-Transition Clinic that can execute the services that will facilitate managing or handling these critical needs. I have established an intervention called post-hospitalisation Care-Transition programme which will seek to address and reduce the above-listed challenges and contribute to the overall enhancement of the health and wellness of patients in Grenada”, said the owner and managing director of Care-Transition Clinic.
“Our goal is to offer care that is unique to each patient’s needs by providing the patient and their caregivers with a tool and the support to encourage them to take up a proactive approach in their self-care and to foster care coordination and continuity across different settings. This intervention is evidence-based and proves to reduce re-hospitalisation, improve patient quality of life and reduce the burden on the healthcare systems in many other countries.”
Joseph has found that her new role within the healthcare system is quite rewarding since it is her passion to provide excellent patient care. “I not only treat the patient’s physical illness, but I also provide leadership advice and motivation to encourage patients to live a healthy life. My passion is evident in each patient interaction, whether I am discussing medical treatment or advising them to remove self-limiting beliefs, my message is always consistent – you don’t let your present situation define your future.”
Joseph explained that the Care-Transition programme is a low-cost, 30-day hospital discharge planning and home follow-up programme, for patients who are at high risk for readmission and to other patients who desire their services post-discharge. She said it is designed to help patients (and their caregivers) to play a more active and effective role in their own healthcare. The care will be provided by a registered nurses/care transition nurses who will be tasked with the responsibility to first visit patients in the hospital to collaborate with their doctors and arrange a post-discharge home visit and to provide them with a personal health record.
“The record, which patients are instructed to share with future healthcare providers, includes a list of their health problems, medications, allergies, and warning signs/symptoms and to closely monitor any red flags. During the home visit, which takes place 24 hours after hospital discharge, the transition nurse reviews the patient’s prescribed medications to confirm there are no dangerous interactions and discusses the medication regimen with the patient. The nurse also does role-play to teach the patient how to effectively communicate his or her needs to their healthcare professionals; reviews any “red flags” in the patient’s health record, including how to manage them and when to contact a doctor and connects the patient with any resources they may need to keep their health on track, which may include referral to other services or specialist. The transition nurse will follow up with phone calls during the 30-day period insure the patient has received necessary medical services, medications, and equipment, and to discuss and answer any questions the patient has, and on the fourth week with a final home visit.”
As a front-line practitioner who worked extensively within the public health care system, Joseph understands that providing these services will take a collaboration of an interdisciplinary team of professionals.
“I have collaborated and continue to collaborate with many private medical doctors within the primary care setting about referrals from our clinic to the doctor’s office with required speciality and referrals from the said doctors to our clinic for recommended services. Similarly, I have written to the Ministry of Health to collaborate with the implementation of a risk assessment form for readmission to be placed in the patient folders. The purpose of this form is for the discharge planning to begin during the admission process so that any challenges or potential barriers that the patient may have can be recognised in the early stage of hospitalisation and the necessary recommendation can be made to our clinic while the patient is receiving treatment. By the time the patient is fit for discharge, a realistic plan can be made for the patient, and the transitioning from hospital to home can be smooth with no confusion and the patients can focus on their recovery.”
As a result of the Covid-19 pandemic, Joseph foresees many challenges in operating such a facility but remain optimistic after having adhered to health protocols established by the World Health Organisation (WHO).
“Trying to keep the business afloat, and still not turning away someone who may be in dire need of the services, and can’t afford the cost. Another challenge that I foresee is getting people to continue to the adherence of health practices and to follow through with commitments. As a front line worker at the heart of the unparalleled crisis of Covid-19, trying to reduce the spread of infection; developing suitable short-term strategies; and formulating long-term plans, successfully and maintaining my personal responsibilities, including taking care of my family and my self is also a big challenge. However, despite this, I think it is necessary that we continue to balance these existing obstacles to our health and wellness. I believe that if we continue to adapt to the protocol that has been put in place for by the WHO will bring great results, having fewer cases and bringing us to some form of normalcy.”
Care-Transition Clinic is located at the Bruce Street Mall in St George’s and is described as a nurses-led clinic. It is officially operating and attending to patients daily, and there are plans to officially launch the services offered at the facility in 2021.
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