Safe Transition of Care

    Care transitions are an area in which our healthcare system could certainly use some improvement, since they are, in many cases, the weak link in the chain of care. As responsibility for patient care is handed off from one group to another – acute care to rehab, for instance, or non-acute care to home health agencies, assisted living facilities or family caretakers – important details can often fall through the cracks, affecting patient outcomes and increasing risk of rehospitalizations. Here at Rehab Select, we've made a strong commitment to and investment in optimizing those transitions for our patients and everyone involved in their care.

    Communication lapses during patient care transitions are often key factors in issues like medication mistakes, poor medication compliance and delayed or neglected follow-up care, for example, which increases risk to patients. Care inefficiencies can also become an issue when communication is spotty, such as redundant testing and/or treatment. For these reasons, Rehab Select has developed a comprehensive process to ensure more efficient and effective communication between all parties involved in patient care transitions.

    Among the many steps we've taken to improve and streamline communication during care transitions is using an HIPPA-compliant version of to facilitate virtual meetings between our care team – including nurses, therapists and discharge planners – patients and home health care staff and/or family who will be aiding patients after they leave our care. Bringing all involved parties face-to-face – a process we call a warm hand-off – gives healthcare professionals and family caretakers an opportunity to clarify treatment and/or rehabilitation goals and share input and observations for more effective care coordination and improved continuity and quality of care. Our warm hand-off process also gives patients and new care providers the opportunity to meet virtually, making the transition of care more comfortable and secure.

    In-depth patient risk assessment is another step we've taken to help better ensure safe transitions of care. We look into a number of potential risk factors with the goal of mitigating those risks, such as whether or not patients have adequate support upon discharge, transportation, a drug store they use regularly to fill prescriptions and if they are likely to be active and engaged in their community after discharge. These potential impediments to a safe transition to home are often a factor in patient success and satisfaction, as well as in the risk of rehospitalization; having an accurate picture of them is important to promoting excellent patient outcomes.

    These are just a few of the many enhancements and improvements we've made to our transition of care and follow-up processes, so please feel free to contact us to see what else we're doing to help ensure smooth, seamless and safe transitions for the sake of our patients and fellow healthcare professionals. Why does Rehab Select go above and beyond the practices of other facilities when it comes to transitions of care and follow-up? The goal – one that we've definitely seen success with – is to improve patient outcomes, ensuring they have the support and care they need to stay healthy and out of the hospital – despite today's shorter average stays in care. In short, we go above and beyond because we believe that quality care shouldn't end when a patient leaves one of our Rehab Select facilities.


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