Strokes: Transitions of Care

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Stroke is the number one cause of disability, and can cause drastic changes to a person’s quality of life. Cone Health is dedicated to helping patients regain their functionality after stroke, in the hospital and at home. To help patients transition back to their own home, Cone Health and Triad HealthCare Network partnered together to create the Transitions of Care program.

When a patient is released from the hospital after having a stroke, they are given instructions on what medicines to take, when to take them, and what rehabilitation therapy would help them on their road to recovery. Once patients get home, trying to get everything done can feel overwhelming. That’s where Transitions of Care comes in. We have a call system designed to follow up with patients to see if they need help, and then provide thirty days of monitored support to make sure they are on track with recovery.

The most common problems patients have after returning home include: setting up rehabilitation appointments, finding a ride to their follow-up appointments, and getting the medication they need. If one of these issues is discovered in the follow-up call, Triad HealthCare Network Care Management provide nurses, social workers and pharmacists to help them resolve the problem and to act as a patient advocate. In those first thirty days post-discharge, patients in the Transitions of Care program can call their care management team anytime to assist in their daily needs of managing their condition.

Many patients don’t realize they need help until they leave the hospital. For example, we had one patient that forgot to fill their prescriptions before leaving the hospital, so we requested enough medication for the next thirty days be sent to their local pharmacy at no cost to the patient. At Cone Health, we want to make sure our patients continue getting better, even after they return home. The Transitions of Care program streamlines patient follow-up, giving patients one place to ask all of their questions, as we gather and organize the care they need.

Spokesperson Background:

Michelle Bednarek is a project management specialist for Triad HealthCare Network. She received her Bachelor of Arts in communication from the University of North Carolina in 2002 and a masters in health care administration from Pfeiffer University in 2014.