Being discharged from the hospital, or a care facility, into the hands of “home health care providers” can be a confusing time with a lot of moving pieces. And while it’s often a relief to be heading to the familiarity and comfort of home, with that relief can come anxiety.
Who are “home health care providers”? What do they do? When do they come? How do you decide which home health care agency you want? And who helps ensure that nothing gets lost in translation as you transition from facility to home?
RVNA’s Katy Johannssen (pictured above center with RVNA Home Health Navigators, Karen Marino, left, and Gladys Llantin-Tucci, right) who, as a member of RVNA’s Home Health Navigator team, has helped transition RVNA patients from hospitals and care facilities to their homes for over seven years, helps provide clarity on how it all works:
Q: What and who are Home Health Care Providers?
A: Home Health Care Providers are medical and non-medical practitioners in different disciplines — nurses, physical, speech and occupational therapists, home health aides, medical social workers —who visit patients in their homes after they have been released from a hospital or other care setting. A patient’s physician refers the patient for Home Health Care, recognizing that they may be ready to leave the hospital or care facility, but may still require certain medical or non-medical care as they recover at home. Nobody wants to return to the hospital, and Home Health Care Providers are key to keeping patients on the track to recovery.
Q: Does a patient decide which Home Health Care agency they use, or is one assigned to them?
A: By Connecticut state law, all patients must be given a choice of three Home Health Care agencies while they are in the hospital. The list of agencies is typically provided by a hospital case manager and the patient makes the choice. If the patient knows which agency they want, it is very important for them to ask for that agency by name. If a patient does not know, they have the right to meet with representatives from all the agencies recommended to them. Patients and their families should definitely take advantage of this!
RVNA’s Home Health Navigators regularly meet with patients and their families to help them understand what RVNA does, who we are, how we work and what they can expect after they ‘graduate’ from the hospital or care facility. Our job as RVNA Home Health Navigators is to ensure as seamless a transition as possible and, for me, that starts with meeting potential patients and their families, as appropriate, helping allay any concerns or anxieties and ensuring that we understand and can meet their needs and they understand what to expect.
Q: Who helps ensure that nothing gets lost in translation as you transition from facility to home?
A: It is the role of the Home Health Navigator to bridge the gap between hospital and home. We work carefully to capture all relevant information, instructions and details — both clinical and non-clinical — so that the RVNA team can hit the ground running when the patient arrives home. We confer with the patient and their family, with the patient’s medical team, the case manager, and we conduct a complete review of medical records and the patient’s chart to understand the treatments, therapies and medications the patient requires.
RVNA needs the complete picture of a patient so we can best serve them at home. Getting this information right and communicating it effectively is critical to a patient’s recovery.
Q: What do you like most about your role as a Home Health Navigator?
Without a doubt, the patients. I enjoy meeting with them and helping ease their minds, so they can transition home comfortably and confidently, knowing what to expect.