When a patient leaves the hospital, what type of healthcare will they receive? Is the medical team qualified to address the patient’s needs? Will they support the patient’s transitions?

These are some of the questions that challenge physicians, caregivers, discharge managers and case workers as the patient transitions from the intense hospital environment to a post acute, sub acute or transitional care facility. At Kissito Post Acute, we acknowledge this challenge and immediately create a feeling of trust, security and open communication between the medical team and caregiver/patient.

Hospitalization and post acute (hospital) care are stressful and challenging for families and caregivers. Because the patient is likely to be seriously ill or experience a significant decline in function, there may be a great deal of uncertainty involved with his/her prognosis. Often, the caregiver feels helpless and out of control with little communication or input to the medical team.

Kissito Post Acute focuses the care on the patient’s needs by building an interactive, collaborative relationship between the patient, caregiver and its Total Care Medical Team. Together with input from the patient and family, the team determines the most effective and efficient treatment plan, based on Best Practices to help maximize the patient’s independence and return home safely.

As Post Acute Care is often clinically complex, our Team is interdisciplinary and comprehensive. It offers 24/7 care with medical professionals including Nurse Practitioners, RNs, therapists, social workers, and case workers.  In fact our Nurse: Patient Ratio exceeds the national average.

After the patient’s admitting diagnosis and assessment, our Team utilizes one of our 23 Collaborative Care Pathways to guide the care plan. The Team members collaborate to develop clear objectives and then deliver care using Evidence Based Medicine. Team members keep one another, as well as patients and their loved ones, informed every step of the way to improved health and functioning.

Based on the traditional teaching hospital of Grand Rounds, the Total Care Medical Team has evolved Collaborative Care Rounds for the Post Acute patient.  On a regular basis the Team provides Rounds to each patient.  This provides an opportunity for both the patient and caregiver to interact with team and for the team to track the progress of the patient and address their needs. 

Phase 1

Joint Case Management & Pre- Admission Review (Pre-Admission)

Transition always presents risk. To eliminate the risk of re-hospitalization and medical error our model provides for a formalized system and HL7 compliant Electronic Medical Record, developed by physician staff to obtain specific information based on individual diagnoses pre-admission. This in turn allows Kissito Healthcare to provide a safe care transition that leaves minimal risk for hospital re-admission and medical error. As a bi-product of this system Kissito Healthcare is able to take a more medically complex patient earlier from the hospital.

Phase 2

Orientation & Assessment (First 24-48hrs)

ORIENTATION is conducted using a comprehensive easy to understand guidebook that helps to set the goals and expectations for both the patient and the family. Each patient and family is seen by their interdisciplinary team via what we call Collaborative Care Rounds. The interdisciplinary team is made up of therapists, nurse practitioners, social workers, nurses, and dietitians. The orientation process ensures that both the patient and family know they will be active participants in the rehabilitation process day one.

Phase 3

Treatment Phase (48hrs – 3 days prior to discharge)

TREATMENT planning is a crucial phase in the model. No one patient has the same treatment plan. A comprehensive tool called the Collaborative Care Pathway™ was developed to help guide the development and execution of purposeful treatment plans designed individually with the goal of returning the patient back to home. Based on 12 months of research and constant collaboration with healthcare providers, the Collaborative Care Pathway™ consists of staff competency and skills training, templated documentation, and use of industry best practices. This ensures that the staff and medical team are in tune with the patients every need and are equipped with the skills and knowledge to identify red flags and problems early enough to prevent hospital re-admissions.

Phase 4

Transition (3 days prior to discharge)

TRANSITION U is a program created for the patient and the family that allows the patient to start to takeover their care. Once this transition has begun the interdisciplinary team is able to step outside the box and really see where the patient’s progress really is and identify potential failures or areas that need to be addressed. Transition U not only prepares the patient to go home but it also includes processes like home safety evaluations and teaches medication management.

TRANSITION U introduces the patient and family to their Transition Coach. The Transition Coach becomes their key contact for preparing them to be able to not only go home, but remains their contact once they get home.

Phase 5

Home (Post Discharge): Home Phase is being implemented in early 2010

HOME but it’s not the end of the road. It’s the beginning of a new road, and not one that leads back to the hospital. Once the patient returns safely to home they are visited within 24-48 hours after discharge by their Transition Coach to ensure they are comfortable self administering and managing their medications, completing any exercises or therapy related items that were assigned, but most importantly to make sure they can function in the actual home.

Each patient is given the number to the Kissito Care line and the direct number to their Transition Coach. The Kissito Care line is simply a channel for the patient to ask questions related to their transition and care. No medical information or advice is given; however the care line attendant will refer them to a medical doctor should they ask for medical advice.